Hello, my name is Alex Christ, and I'm going to spend the next four hours with you talking about clinical preventive medicine, and this is a big topic. We have a lot to cover during this time, and hopefully what I'll share with you will help you with preparing for your board exams, and I'll try to put everything I say here into the context of what you might expect to be asked about the board exams, but I don't get to make the questions, so I don't actually know what they're going to ask you. Just as a little bit of background, so I'm a family physician, and I teach and practice at the Fairfax Family Practice Residency. I've been there since 1999, and I think I looked the other day, and I've trained 208 family physicians now throughout my career. One of the other hats that I wear is that I direct a primary care practice-based research network called the Virginia Ambulatory Care Outcomes Research Network. We have 524 practices that do research with us. They're all primary care. They represent the whole scope and spectrum of primary care practices throughout Virginia. That's what I'm trying to show on this slide. I also had the privilege of serving as a prior member and chair of the U.S. Preventive Services Task Force from 2014 to 2021. If you don't like any recommendations after 2021, don't blame me. It's not my fault, but I am perfectly fine being held accountable for all the recommendations prior to 2021. All right, so let's jump into the meat of this talk here. We're going to cover all of clinical preventive services, so this includes lifestyle counseling, screening tests, immunizations, chemo prevention. We're not talking about tertiary prevention, so primary prevention is preventing something from happening before it happens. Secondary prevention is finding something early when you can do something about it and treat it. And tertiary prevention is much more about treating people with chronic conditions. So someone's had a heart attack, how do we prevent them from having another heart attack? We're talking about population screening and population counseling, and we're taking a primary care perspective for this session here. So we're not really necessarily talking about recommendations that would apply to other settings, things like occupational medicine or research surveillance or those types of things. So the U.S. Preventive Services Task Force, I suspect most of you know what this is. It's a federally supported agency, but it's independent. There's 16 experts from primary care disciplines. They're supported by the Agency for Healthcare Research and Quality, and they're these evidence-based practice centers that do really all the work of reviewing the evidence, putting together the systematic reviews, and giving this to the task force members so that they can make good informed decisions about guidelines. The task force is supported by a wide array of professional societies, including ACPM, and the recommendations are updated regularly. In general, it's about every five years, but it depends a little bit on the evidence and how the evidence is evolving. So what you're going to see throughout this presentation is I tried to put a date of when the task force last updated it to orient you as to what to be thinking about for questions. There's going to be a couple places I'm going to talk about some new changes to guidelines that may not be on your boards. Generally speaking, though, anything within the past one to two years may be fair to think about, and there's a number of cases where the guideline has been updated very recently, but it's not really fundamentally different. So the guideline as it currently stands will be exactly what you're trying to answer for your boards. Do you want to keep up to date with the task force? There's a listserv. Sign up for it. They'll send you emails every time there's an update. So there's a general process that the task force uses, and this may or may not be on your boards, but I want you to be aware of it, and it's a process that is really open for and actively solicits public input. So you can get involved and you can help the task force with making recommendations. So to start with, anyone can nominate a topic. If you think there's a preventive service that the task force hasn't covered that they should, go to the website and nominate a topic. The task force starts out each recommendation by creating a research plan. Now this is not a research plan like researchers think about. The research plan is how they're going to do the evidence review to be able to assemble the evidence for the task force members. There's a draft research plan that comes out, and the task force actively solicits comments from experts, but anyone from the public can comment. And then after the task force makes its recommendation, it starts with a draft recommendation and it publishes that for public comment. Once again, the task force is soliciting comments from experts and from anyone who wants to comment, and then from that, they create a final recommendation. So each one of these steps is open for public input. So everything I'm going to talk about, it's all on the website. So as you're thinking about your career and moving forward and staying up to date, it's all on the task force website if you want to follow their guidelines. And all the things that I'm going to talk about with these slides, I pulled from the website. So you can have the recommendations, you can get the full systematic reviews, there are the announcements, there's all the methods papers, the reports to Congress, and conflicts of interest and task force members. It's a very rich website. So this is just kind of giving you some organization on the website. A lot of people look at that very first red box up there. That's the top line recommendation. It kind of says, do this, don't do this. But you'll notice if you scan down below on the website, there's tons and tons of helpful information here. So that next red box I circled is the supporting evidence. That's where you'll find the systematic review. These are often two to 400 pages. And if you want to find all the evidence on all the high grade evidence on a topic, this is the place to go. There's the table of contents as well. And you can see under the full recommendation, there are these headers like importance, U.S. Preventive Services Task Force assessment, the practice considerations. So like the practice considerations is a lot of where kind of the nuance of how do you implement the preventive service comes into play. You'll see below there's research needs and gaps. So for every topic, even when we have good evidence, there's still gaps in what we know and the task force is trying to call that out. And you'll see recommendations from others. So if you want to go and say, well, what does any professional society make in terms of recommendations for breast cancer screening, you can click there under mammogram and it'll link you to really all the big national ones that matter. It doesn't get to every single little state or different professional organizations recommendation, but it does get to the big ones. We're going to talk about I statements here and, you know, look at the full recommendation statement. There's some suggestions about how to put an I statement into practice. And there's a call out on the research needs and the gaps. An I statement, if you're not aware right now, means that there's insufficient evidence for the task force to recommend for or against a preventive service. It's a call for more evidence and that's a really important thing. And there's also some educational material for patients. So this is for prostate cancer screening that I got to be involved with. There's a video explaining things, which can be good for clinicians or patients. There's a handout that can be given to patients. So there's a number of these consumer related information to pull from. And there's an app for your phone, if you'd like, it's called the prevention task force that you can download. Today I'm going to talk about not just the U.S. Preventive Services Task Force guidelines. I'm going to pull from a number of different groups. And I'll say which ones I'm pulling from to guide you and I'll try to call out the differences. So as you're taking your boards, you know, look at the question and see what they say. If they say, what does the American College of Obstetricians and Gynecologists recommend for cervical cancer screening, you know, that'll cue you in that, no, we're leaving what the task force says and we're going to this other group. I don't think you're going to get a ton of those. If they don't say which guideline they're referring to about what you should or shouldn't do, I would always answer from the framework of the U.S. Preventive Services Task Force. I think that's how the boards are going to be set up. We're going to pull from other sources, though. There's the Community Guide to Preventive Services. This is more public health and community interventions. There's the Dietary Guidelines for Americans about diet and exercise. That's updated every five years. There's Healthy People 2020, which is our nation's roadmap on health and prevention. So let's talk about the methods that the U.S. Preventive Services Task Force uses. I think this is fair game for boards. The task force is explicit and evidence-based. They're trying to create an objective process that if you bring any 16 people together and they go through the same process, they'll come up with the same answer. And they mostly do this. The other thing that the task force does is they define clinical endpoints of interest. So they care about health outcomes, which means anything that extends the length of the quality of life. And they're not as interested in the intermediate outcomes. I say not as interested because intermediate outcomes are important in kind of getting some of that confidence that the evidence is giving you an answer. And you want to see changes in health outcomes and intermediate outcomes that lead to health outcomes so that you can have confidence that this evidence is showing you a convincing story that doing X, Y, or Z changes an outcome. But unless it changes a health outcome, the task force isn't going to recommend it. They do a systematic search, as I mentioned. They're looking at the strength of the evidence and does it apply to prevention and to primary care? Does it apply to a population of people who don't have signs and symptoms of illnesses? And then they're evaluating the benefits and harms of each service. And they're looking at different groups, so by age, by sex, but also other types of groups that may be affected more or less by different conditions. And that's where they're explicitly looking for the evidence for subpopulations. So which groups of people in which communities are impacted more by a condition or have differential outcomes with preventive services and why? And what does that mean in terms of guidelines? So the task force is looking really at two things. They start with the certainty of the evidence. So if we put all the evidence together, how certain are we that we can say that this helps or hurts people? And then the second thing they're looking at is the magnitude of the net benefit. So this is both the magnitude of the benefits, the magnitude of the harms, and you want a preventive service that's going to help more people than it's going to hurt. And when there's insufficient evidence, the task force doesn't replace this with expert opinion. So plenty of guidelines I was on, I know what I think as a clinician and as a person we should or shouldn't be doing, but if the evidence doesn't back that up, the task force gives it an eye, which is a call for more evidence. So an A and a B, you probably know means to do things generally in practice. This is the grid and the lens the task force is taking. A B means that you have at least moderate certainty of a moderate net benefit. An A means you have high certainty of a substantial net benefit. So there aren't a ton of A recommendations. And just because something's an A and another thing is a B, it doesn't mean that the A has a greater net benefit. Most of the B recommendations are a B because of a moderate certainty of the evidence, not because of the magnitude of the net benefit. What I also want you to see is a C recommendation, that means we have at least a moderate certainty of a small net benefit. So a C is a recommendation to do a preventive service, but it's a recommendation to do it selectively. We'll talk about this throughout. And then the D recommendation generally means to not routinely do something. So it means we've got moderate certainty that it either has zero net benefit or that it actually hurts people. It doesn't mean you wouldn't do a D service. So I'll get PSAs on men over 70, but I'm not doing it for prevention. I'm doing it for other reasons. So here's what it means in practice, A and B routinely offer these, C selectively offer it, D routinely discourage the use of it, and an I is a call for more evidence. So that C, the selectively offering it, could be a number of different ways of putting into practice, might be shared decision-making, so value-dependent. So if you go by the prior task force recommendation for breast cancer screening for 40 and 49-year-old women, whether you start in your 40s or 50s depends on your values. It might also be patient risk. So the C recommendation for aspirin for men and women with a 10% 10-year risk, it depends a little bit on, there are other risk factors that go into calculating this beyond just the cardiovascular calculator. And it might be patient readiness. So the routine counseling for healthy diet and exercise for non-obese people without cardiovascular risk factors might be about, is this person wanting to talk about this? And does it make sense to talk about it? I know as a physician, if I'm seeing someone and they have a million other issues, and I want to get them to quit smoking or drink less or something else, I might not address diet and exercise. But my other patients who are coming in asking about it, you bet I address this and we talk about it. Here's the task force's view of shared decision-making. It was done in 2004. There's been some updates since, but I think this holds. The idea is that people understand the risk or seriousness of the condition that's being prevented. People understand the preventive service, including the risks, benefits, alternatives, and uncertainties. And a person's had a chance to weigh their values regarding the potential benefits and harms of the service. And then they've been engaged in the decision at the level that they want to be. So if a patient looks at me and says, doc, I don't know, you're the doctor, tell me what to do. And I tell them what to do, but make sure that they understand the condition and the preventive service and try to think about injecting my impression of their values into a decision. That's a shared decision for that patient. I mentioned that I statements are calls for more evidence. And here's just a really fun policy piece. Every year the task force prepares a report to Congress on evidence gaps. So here are ones from 2013 through 2020. Of course, there's been one every year since 2020. They often have a focus based on the task force's recommendations that year. And it's laying out a roadmap for the research our nation needs for Congress. Congress gives this to the Office of Disease Prevention. And ODP then tracks NIH for funding research to close these evidence gaps. It's a great process to build knowledge. So a lot of people get frustrated at the task force when they say, well, you know, it's great that you can say there's insufficient evidence, but I'm a clinician. I need to decide if I'm going to do it or not do it for someone. Tell me what to do. But there's value and need for us to know what we know and know what we don't know. And that's what this process is about. Some caveats, which I've mentioned. This is about routine use in average risk patients. Clinical judgment and individual factors are important. Task force recommendations are not considering insurance coverage or availability. It doesn't take into account patient preference, liability concerns, cost or cost effectiveness. So when the task force is looking at this evidence, they're not saying, oh, gee, you know, a FIT test for colon cancer screening costs, you know, a fraction of a Cologuard test and has the same health outcomes, we should recommend the FIT test. The task force is looking at both of these tests and saying there's evidence. We have moderate certainty that there's a moderate net benefit. So we're recommending both of these services. So as a clinician or a policymaker or another person thinking about this, you know, we need other people to inject those types of decision-making processes into how we actually implement task force recommendations individually and on a national level. Now, I say the task force isn't considering coverage, but I think everyone here knows that task force guidelines are linked to coverage. So this was part of the Affordable Care Act. Prior to the Affordable Care Act, it literally took an act of Congress in order for Medicare to cover preventive services. Now Medicare can cover preventive services if it's an A or B task force recommendation. And commercial insurances and others are mandated to have first-dollar coverage for A and B services. That means paying for the preventive service without any co-pays or other costs. And this is really important for making sure that our nation gets the preventive care it needs. I'll say just because this might come up on your boards, the Affordable Care Act also mandates coverage of any immunizations that the Advisory Committee on Immunization Practices recommends, and it also mandates coverage of recommendations for children that the American Academy of Pediatrics' Bright Futures groups makes. So those are all important entities linked to coverage. And there's a clause in the Affordable Care Act that says that just because the task force doesn't recommend something doesn't mean that it shouldn't be covered. So this is a task force C or a D recommendation is not a call to not cover something. And we need policymakers like Congress to say, look, you know, if there's a C recommendation for screening for mammogram for women 40 to 49, that's fine, but we're going to make a law to mandate coverage for all women starting at 40. And that's the system working as it should work. So here's the analytic framework and the research plan. I'm making air quotes if you were to see me in person, that the task force puts together for like a screening service, and they look at each of these different steps. And they look for overarching evidence, like let's take a whole group of people, randomize them to be screened or not screened, and see what the outcomes are. But they also look at each step of this process, everything from how good is the screening test to how good is their treatment, and then if they're intermediate outcomes, what's the association between the intermediate outcome and reducing morbidity and mortality. And each step of these, the task force looks at the adverse effects as well. So there's a lot of reasons to be cautious about screening. You know, the first is there's a potential to harm healthy people. So screening and preventive care is about doing things to people who feel good, who don't have complaints, otherwise we're getting into the realm of practicing medicine. So there's this risk of taking someone who's healthy and making them sick. There's downstream consequences of testing. So invasive procedures, anxiety, among other things, missing work from dealing with healthcare issues, and on a population level, there's a risk of adopting new tests too early, ruining chances of finding out what really works. So in the United States, the PLCO trial that was done back in the 90s to try and say does prostate cancer screening work or not work, was really struggling because if you look across the control group across all of the years, something like 78% of people in the control group got a PSA at least once in one of the years that they were followed in this study. So it was really hard to say, to have a control group to compare PSA testing to versus not PSA testing. The other thing to know, and I'm not going to get into the biostats of this, I know you're going to have review sessions on that, is just about the positive predictive value. And, you know, the trouble of screening for uncommon diseases is even if you have a test with decent sensitivity and specificity, you're still much more likely that a positive test still means the person does not have that condition. The more common a condition is, the more likely a positive test is a true positive test. And this is where you'll get different guidelines. So in primary care, in the task force, the lens that they take, it may not make any sense to screen for hemochromatosis, but the American Gastroenterology Association might say, you know, gastroenterologists should screen for this because so many more patients have hemochromatosis. There's also the issue of lead time bias. So, you know, this is the idea, this came out, and the way to think about this concretely is the early lung cancer screening tests were all about chest X-rays. And they randomized people to get a chest X-ray or not get a chest X-ray to look for a lung cancer. And what you found is if you got a chest X-ray, it took you four years before you died. And if you didn't, it took two years before you died. But the problem was if you were slated to die at 72 and you didn't get a chest X-ray, you found it at 70 when you had symptoms. And if you got the chest X-ray, you found it at 68 before you got symptoms, but you still died at 72. We didn't change any outcome there. The length time bias is this idea that screening is going to find kind of the more slow-growing, more indolent types of things and is more likely to miss the fast, more aggressive type things. We sometimes think this might be an issue with prostate cancer screening. You know, there's this type of prostate cancer that, you know, men are not going to die with. They're going to live with their whole life. It's quite easy to find those prostate cancers. But making sure you're finding the prostate cancer that spreads, metastasizes, and kills men in that window where we can change that outcome is where we might be struggling some. Some general practices to know, personal health practices are important. So the health behaviors are the cornerstone of health. You all know that diagram that shows how much healthcare changes outcomes. It's like 20%, you know, behaviors, environment, genetics, structural and social determinants of health, all these things have a bigger impact. A lot of decisions should be shared. These are all guidelines, so ultimately, even if it's a recommended preventive service, it's up to a person and a clinician as to whether to do it. Should be selective about ordering services. So just because we can find something doesn't mean we should. It needs to change that health outcome. Needs to improve the length or the quality of life. And we should take every opportunity to deliver preventive services. So there's a thing called reverse targeting where the person who schedules a wellness visit to come in and get preventive care is probably up to date on their preventive services. The person who's falling through the cracks and not bubbling up into the healthcare system is probably the person who needs it the most. And in many cases, community-based interventions might be more effective. Changing the environment so that the right decisions are easy to make and that the default is a healthy default as opposed to an unhealthy default is so important. And then we have to think about equity throughout prevention. So we're gonna talk about that more for specific recommendations and also I'm gonna get to the social factors and structural factors that influence health. Lot of reasons for disagreement in prevention. There are groups that rely more on intermediate outcomes or surrogate outcomes and put more weight on those than the task force does. There can be different valuing of harms. I think the task force does this well with their C recommendations and you take prostate cancer screening. Prostate cancer saves lives but there are many fold more false positives. So how you value potentially not dying from prostate cancer versus a hundred fold or 200 fold more false positives, that changes whether you wanna do it or not. And then this idea of effectiveness versus efficacy, primary care versus specialty perspective and the idea of doing no harm and the approach to uncertainty. So a lot of people in organizations feel compelled to act on something now because it's hurting people but if we don't know that acting helps people, maybe we shouldn't be doing that but different groups interpret this differently. All right, I already mentioned this at the beginning so I'm gonna skip this to make sure that we don't go over time here but I've got two to three years to develop a board question. I don't know the questions. I'm trying to tell you what I think they might ask you to try and help you the most as you move forward here with this. Now we're gonna move on to cardiovascular disease. Cardiovascular disease is super important. There's a whole bunch of elements here that we're gonna review. These are the bullets of the things that I'm gonna try to cover here but heart disease is the leading cause of death. Stroke's the fifth leading cause of death. A lot of adolescents and adults are not engaging in physical activity. Obesity is rising. Smoking is still present. Hypertension is very common. It's often undertreated as is hypercholesterolemia so there's a lot of factors that are driving the cardiovascular disease being a top driver of death and premature death for the country. So let's get into some recommendations here. So we're gonna start with hypertension and this is the 2021 and 2020 recommendations for hypertension. So the task force recommends screening for high blood pressure for adults over 18 and says there's insufficient evidence to say whether we should or shouldn't screen children for hypertension. A key thing with this recommendation is that the task force is calling out use of multiple measurements. You know, there's white coat hypertension and your reading might be high in the office but you know, this idea of using home monitoring whether that's home ambulatory monitoring to check this or actually just having patients check it at home is an important one. So I could see a board question being something like, you know, would you make a diagnosis based on one reading in the office? And the answer is no. You're gonna also rely on readings outside of the office and multiple readings. The other thing to look for with these guidelines is sort of a little bit of treatment and I never quite know how far to go here when talking about treatment for your boards and such but the guidelines around this were done initially through NHLBI and the Joint Commission on Prevention and Detection of High Blood Pressure. It's now moved to the American College of Cardiology and American Heart Association and they've had updates to their guidelines in 2014 and then 2017. I don't think you need to know this but you know, the old JNC guidelines in the original used to call for, you know, saying that 150 if you're over 60 is where you start thinking of hypertension and under 60, it was 140. We've kind of moved to being a little bit more aggressive about making the diagnosis of hypertension. So I think that's what you need to know for this. There's this trial called the SPRINT trial and then there was another trial after this in 2021 that found that people who are at higher risk of cardiovascular disease had a lower mortality if we aim for a blood pressure of less than 120. So this trial ignored people with or did not include people with diabetes and you know, they found that aiming for a blood pressure of 120 should be the goal here. Now I'll say in this trial just to know there's a lot of caveats. So first this was high risk people. So it's been harder to demonstrate these mortality benefits and lower risk people. The other is when they check this, they put people in a quiet room, they put meditative music, they sit there for 10 minutes. It's a automated machine that takes three average readings. So it's super important that you get an accurate reading. And the trade-off also was in the group that was aiming for 120, you had increased hospitalizations and harms from over-medicating people. So that is a little bit of the trade-off here with this. For your boards, what I would know is that the goal really blood pressure right now for people is this, you know, so we're aiming for, you know, people having a blood pressure less than 140 over 90. There's this category of normal blood pressure of less than 120 over 80, elevated if you're in this in-between range, stage one, stage two, all the numbers are here on this slide. Your people who are at higher risk because of that sprint trial, they're saying aim for a blood pressure less than 130 over 80. And one of the things I didn't say in the sprint trial is that they were aiming for a blood pressure of 120 over 80 in the intervention group, where actually it was just 120 for the systolic, that's what they were focusing on, not the diastolic. And something like 40% of patients didn't get below 120. So the aiming is really important. So, you know, how much you have to give medicine-wise to get someone there is a trade-off as to whether you should intensify medicines or not. But if you're asked on the boards, you know, in general, if patients have a blood pressure over 140 over 90, that's where you, and you're confident of the reading, that's where you might be implementing drug therapy. And there's some medicines that they recommend that you might do with certain groups. I don't know how much you'll need to do this. And this is an area where people are really kind of questioning whether this is accurate or not. But I think what you should know for the boards is that, you know, ACE inhibitors, angiotensin receptor blockers, calcium channel blockers, and thiazide diuretics, those are all really first line blood pressure medicines. I think we do have agreement that people with kidney disease or with diabetes, you probably want to start with an ACE inhibitor or the angiotensin receptor blocker. So that's my, the extent of what I would learn and memorize for your boards around medicines. Statins, so the task force recommendations, this is about statins for primary prevention of cardiovascular disease. So it's not about screening in adults for hyperlipidemia, thinking about statin as a medicine that lowers your risks for having a heart attack or stroke. And the idea is you, the task force is recommending for adults age 40 to 75 who have one or more cardiovascular risks. So this is things like hypertension, hyperlipidemia, diabetes, obesity, they're smoking, and they have a 10% risk or greater. And that's the 10% risk based on the pooled cohort equation or your 10 year cardiovascular risk calculator is where that number comes from. That that group would be recommended to be prescribed a statin to prevent cardiovascular disease. The task force gives it a C recommendation for people with a 10 year risk, the same cohort of people with a 10 year risk between 7.5% and 10%. So, this would kind of depend is, are there other risk factors that are missed in the pooled cohort equation, or for a person who's particularly worried about cardiovascular disease and they wanna be a little bit more aggressive, maybe they wanna start a statin at a 7.5% risk as opposed to waiting to the 10% risk. The other thing I do as a clinician is I start to look at that cutoff age. So, as you get closer to 75, I personally want your percent risk to be higher before I wanna start it, because there's an I statement for 76 and older, there's just not a lot of evidence for people over 76 about statins for primary prevention. Now, I would also note for your boards that if they ask you and say that such and such has cardiovascular disease, should they be on a statin? And the answer to that is yes, at any age. So, if you have cardiovascular disease, a heart attack or a stroke, you should be on a statin for prevention. And I know I just slipped into tertiary prevention, but it's such a common thing. I think that's fair game for your boards. The task force also gave an I statement for screening children. So, this is about measuring lipids to see if they have a high cholesterol level. It's really, we looked really hard to find evidence that this could help us to find kids who have familial hyperlipidemia. That's what you're looking for. Kids with familial hyperlipidemia, they need aggressive treatment with statins and things. But there's not necessarily evidence that measuring this blood test is any better than just family history and getting to know patients as people. The American Academy of Pediatrics recommends checking for hyperlipidemia once in a child's life. So, that might be a place to just kind of read the question. If they're asking generally, should you screen children for hyperlipidemia? I'd say no. Or if they ask, does the task force suggest it? I would say the task force says there's insufficient evidence. If they say the American Academy of Pediatrics recommends it, I would say yes. This is, I put up here the ACC AHA guidelines. I like their 2013 guideline. And if you're from ACC AHA, I apologize for saying this, I don't like your 2018 guideline. 2013 was great because it was very similar to the task force where it's just saying, if you have a risk, you should take a cholesterol medicine. And it was about a fixed dose. So, if you're high risk, you do a high potency statin. And if you're middle risk, maybe you do a mid potency statin. Their 2018 guidelines got all back into titrating to this LDL and that LDL. And all of the evidence on statins is really about randomizing groups of people to a fixed doses of statins, depending on their risk. And in many cases, it's a high potency. There's just not a lot of evidence that medically titrating people to an LDL level changes an outcome. We have great evidence that if you have higher LDL, or if you have lower HDL, that you're more likely to have a heart attack or stroke. That's true. But the question really comes in is, should we change your medicines just around that? There's some bits, I put here, you probably won't be tested on the 2018 recommendations. I just feel that the nitty gritty of this, like these different LDL levels, isn't gonna bubble up into your board questions. But here's where you get the guideline recommendation about if you have cardiovascular disease, you should be on a statin of any age. And if you can tolerate the high intensity, that's what you should be on. If you have an LDL above 190, which is kind of a surrogate for familial hyperlipidemia, you should be on a high intensity. If you have diabetes, this is where the American Heart Association says, and the American Diabetes Association says, you should be on a statin. The task force includes diabetes as one of those risks for the 10 year cardiovascular risk calculator. And that's what I follow personally. So a 45 year old patient of mine who has diabetes, who's otherwise doing well health wise, doesn't necessarily have a 10% risk of cardiovascular disease, and may not need a statin until a little later. Most people with diabetes at some point in their life will need it. But this is a place to look at difference and read the question as to what guideline they're asking you about. And then the American Heart Association says that everyone with a risk above 7.5% should be on a moderate to high intensity statin. And that's where the task force, remember, says it's a C from 7.5 to 10. And if you go and you play around with the calculator, one of the problems is almost any man 65 to 75 has a 7.5% risk. I mean, you can have the best cholesterol in the world and eat right and exercise and run marathons and a low blood pressure and be skinny. But just because you're a man at 70, you have a certain risk of having a heart attack and that doesn't change. So that's where personally, I don't completely agree with saying everyone over 7.5. I don't think you'll get into dosing on these things, but just in general, what you should know is that at 40 to 80 is in your high intensity and resuvastatin 20 or 40 is high intensity. And then all these other lower doses of these are the moderate intensity. You might get asked, what should you put someone with heart disease on? And it would be that atorvastatin 40 or resuvastatin 20. I don't know how much you'll get into that, but this is the fixed dosing and how you classify them. So now let's pivot to screening for abdominal aortic aneurysm. It was updated in 2019 and this has been pretty constant recommendation in the past two or three times. So men 65 to 75 who have ever smoked should have a one-time screening for a AAA with an ultrasound. Ever smoked is defined as 100 cigarettes in your lifetime. It's arbitrarily picked, but it's probably pretty reasonable. And men 65 to 75 who have never smoked this would be a C to selectively offer it. You kind of want to think about their other risks and everything. And then women who have never smoked, it's a D. You wouldn't want to do this for screening. You might for other reasons. And it's an I for women who have ever smoked. So we don't really know. And partly the problems here with this just to know is the AAA surgery has a lot of morbidity and even mortality with it. So when you find a AAA and you fix it, that is not a low-risk surgery. It can be done open or endovascularly. Either one has high risks. And so you have to have a pretty good bang for your buck in preventing this from spontaneously rupturing in the future in order for it to be worth that upfront risk for patients. All right, now we're going to pivot to assessing cardiovascular risk assessment with nontraditional risk factors. So this is like your ankle brachial index to look for vascular disease. It's your high sensitivity C-reactive protein. It's your coronary calcium, these types of tests. And the US Preventive Services Task Force gives us an I recommendation. If you go back and you look at the 2018 ACC AHA statin guidelines, they actually say that for patients who are kind of on the fence as to whether to start a statin or not and get a coronary calcium to help you decide, we'll talk about this. But I'll just share, at least as a clinician, what I've usually found is it's not so much a score like a coronary calcium if people are sort of in this intermediate range, but much more about how worried are they about cardiovascular disease versus how much do they not want to take a medicine. So I find shared decision-making so much more helpful. But here's the general gist of these nontraditional risk factors. There is good evidence that these nontraditional risk factors increase a person's 10-year cardiovascular risk. So if you have a high coronary artery calcium score and your 10-year cardiovascular risk is 10%, you're actually at a higher risk than 10%. You're probably more like a 15% or so, depending on what your score is. The problem, though, is that there isn't a lot of evidence to say, okay, by knowing this and doing something different, do we change an outcome? So I have a lot of cardiologists in my community that routinely get coronary calcium scores on patients. And as a family physician, I just don't know what to do with this because I'm already trying to have them control their risks in terms of blood pressure and cholesterol and eat right and exercise and not smoke. And those are the things that you would do with this. And in kids, just as an example, we looked for evidence on the stat or screening for cholesterol, like does finding high cholesterol levels in kids mean that when you counsel them to eat right and exercise, they're more likely to have healthy behaviors? And the answer to that is no. So a high coronary calcium, yes, it means you're at higher risk. It means I should control all your cardiovascular risk factors, but I should be controlling that anyway as a clinician. And most patients, at least looking at the data, are not gonna change their health behaviors any differently than they would just with good counseling and talking to them about health behaviors. There's also a problem of negative non-events. There's a certain number of people who have a zero for the coronary calcium score who go on to have a heart attack or stroke in the next couple of years. The high sensitivity CRP, similar to the ankle brachial index in coronary calcium, it has been shown if you have a high value, you're at greater risk of cardiovascular disease. There was this trial called the JUPITER trial done in early 2000s, late 1990s. And it did show a benefit with adding a statin if you had a high CRP and a low HDL. But part of the problem with that study is half of the patients in that study would have met criteria to be on a statin based on the current guidelines. So was it the CRP telling us this or was it the fact that this study included people who should be on a statin anyway? So there's some troubles with that evidence. Here's just a little thought experiment. The task force looked at this closely around risk reclassification. And you will see that with these different tests, you can reclassify people's risks. Certain what are gonna be appropriately reclassified where people will go on to have an event, but then there'll also be inappropriate reclassification where they don't go on to have an event or you'll lower a person's risk and they'll have an event to some extent, even though their risk has been lowered by a better score. So we really need to build out the science to understand what do we do with this information before we routinely inject it into practice. That's what I would be looking for on a board review question if you're asked this. So yes, independently, these increase your risk. What do we do with it? We don't know. So now let's talk about peripheral artery disease screening. So the task force gives this an eye as well. So the prior one had ABI, which was thinking about finding peripheral artery disease to use that as a risk factor to address your overall cardiovascular risk. This is about the task force finding peripheral artery disease to treat it. And it's an eye. We know, but the gist of it that you should know and that I think is important with this is that peripheral artery disease tends to be a symptomatic disease, not an asymptomatic disease. So most people who have peripheral artery disease are gonna have pain. They have claudication. It's like angina, but it's in your calf when you walk. So you get a very classic story. So like whether finding peripheral artery disease and treating it, which would primarily be through surgery outside of the other recommendation where you're modifying the cardiovascular risk factors, we don't have evidence that doing that goes on to lower complications like amputations or ulcers or hospitalizations for infections or things like that. So it's an eye because there haven't been great studies either, but we don't have a lot of data on this. Coronary artery disease screening is a D. I would ask you this question because there's a lot of I's here, but this is something you shouldn't do. And this is all asymptomatic adults the task force recommends against screening folks. If someone comes to the hospital and they have a TIA, a temporary ischemic attack or a stroke, we should be looking for this and we should treat it. The treatment for carotid artery disease is bypass and stenting of this. And that causes a certain number of strokes. There was a study in the early 2000s that was published at some very good surgical centers where they had very low complication rates. And it showed that if you screen people for carotid artery disease and you did surgery that over five years, they had less strokes. It looked very promising and encouraging. And then the screening and checking for this got really taken up in the Medicare population. And some people then look back at the data and said, okay, well, what happened when you roll this out to the general population? And the answer is you caused more strokes. This is a classic example of effectiveness versus efficacy. So you have good efficacy when this is done in the best surgical centers with the lowest complication rates, but it's effectiveness when you do this across the US is that you hurt more people than you help. This is about screening with an EKG or echocardiogram or stress test. So the task force gives it a D for adults at low risk of cardiovascular events and the task force gives it an I for adults with intermediate or high risk. So, you know, we advertise to the public that heart disease is often unrecognized by people and we want people to recognize signs and symptoms. It does tend to be a symptomatic condition for people without diabetes. So we want people to look for pressure in their chest, shortness of breath. If they're having that, we should be doing this. But asymptomatic low risk, there's good data that there's lots of false positives and abnormalities that send us down this rabbit hole that leads to interventions, procedures, other things that are not better than doing just traditional medical management and cardiovascular disease prevention. Now, when you're very high risk people who have lots of other risk factors or these strong family histories, we just don't know. And that's really an individual decision. So here are all the harms. There's lots of abnormalities that are just nonspecific. False positives are very high. False negatives are super high. Like an EKG, even if you have coronary artery disease, if you're just laying on an exam table and they do an EKG, you're not likely to have ischemia at that moment. So it's going to be normal. The follow-up can be expensive. Task force isn't looking at that, but it is invasive. So it leads to things like stents and cabbages and surgeries and procedures, which have complications and other things. And here's some data about how often people end up going down this path of getting an angiogram or undergoing revascularization without evidence of benefit in folks who have diabetes who got a stress test. It's 6 to 12% for angiograms and 3 to 5% for revascularization without evidence of benefit, meaning that they probably shouldn't have gone there. Screening for AFib was done January 2022. It was also done, I think, 2018, and it was an aye both times. So the task force has said, well, there's insufficient evidence to recommend floor against screening for AFib. Now we hear about this all the time. And as a physician, I hear about it a lot because all my patients have Apple watches and they're like, oh, my watch showed this or it showed that. What should I do? And that gets to be super confusing. But when we're talking about screening, this is about things like everything from an EKG to doing a pulse ox to ambulatory monitors like your Apple watch, the consumer directed devices, and even just feeling for pulses. We don't know. There was this big study called Stroke Stop. This was interesting. 28,000 people, and they mailed them an invitation. It was done in the United Kingdom, I believe, to come in and be screened for AFib versus not. And if they came in, they got a 12 lead EKG and did a whole handheld recorder for intermittent recordings over two weeks. And half of people invited to participate did, the other half didn't. And they found unknown AFib for about 3% of those that were screened. So that's pretty high, 7,000 people. And actually most of those people accepted the oral anticoagulation. So that's the idea. You find AFib, you anticoagulate them and you prevent them from having a stroke due to AFib. But it didn't change the rates of strokes in folks. So if we have 7,000 people, I mean, and if we have, I'm sorry, excuse me, if we have 3% of the 7,000 people were screened with AFib and doing this treatment and we're not showing changes in strokes, that's a little concerning that it might not work. But the task force gave it an eye saying we need more evidence and stronger studies with bigger populations. But one way to think about this is AFib tends to be a symptomatic condition. People tend to feel it when they go into AFib or they're having reduced energy exercise capacity, those types of things. So what we need to think about is, is screen detected AFib the same as symptomatic AFib in terms of your risk of having a stroke over your lifetime? They may be different conditions. So that's why it's so important to have these types of trials and to close this evidence to understand it. Now I'm going to talk about aspirin. So this was updated in January of 2022. This falls into this category of, okay, are they going to have the January recommendation from 2022 or are they going to have the old one? I'd like to think that by this time the board review question people would have removed a question if it was not consistent with the January 2022 recommendation. But maybe that's just me here. The task force changed it. The way this changed used to be more of a B recommendation for people who were older and at 10% cardiovascular risk. And then a C for if you were younger and at the risk. So actually I had that reversed. It was a B for people who were 40 to 50 and had a 10% risk. And it was a C for people who were 50 to 60 and had a 10% risk. Just the idea being that younger people have more years to benefit from this. Like I said, I'd like to think they're going to get rid of that. So I'd like you to remember this guideline here. So the task force is giving this a C for adults 40 to 59 with a 10% or greater risk to prevent cardiovascular disease. And they're giving it a D for adults 60 and older for prevention of cardiovascular disease. So this is for primary prevention. If you get asked about whether someone who has had a heart attack or stroke, should they be on aspirin? The answer is yes. We're talking about people who have not had a heart attack or stroke. It doesn't matter whether they've had diabetes. It doesn't matter if they have hypertension or other things because you're using the 10-year cardiovascular risk factor. That's really what you're doing. And the reason I'd like to also think that this question would be adapted for the new guidelines is we had a series of studies coming out really from 2015 on that started to question the routine value of aspirin for primary prevention. So while I say question the routine value, when the task force made this guideline recommendation, the news came out and said the task force stopped recommending it. Go back and remember a C means to selectively offer it to people. So the task force is recommending aspirin for people 40 to 59 at greater cardiovascular risk selectively. Depends on the benefits they might have, their overall cardiovascular risk profile, as well as the harms they might suffer from bleeding from aspirin. But these three trials came out that changed our understanding of aspirin. So the first was this ARRIVE study that looked at older men and women, meaning over 55, but their average risk, not higher risk. And there was no benefit in cardiovascular disease prevention. And there was an increased risk of bleeding. And then we have the ASCEND study, which looked at people over 40 with diabetes. And it did show it reduced cardiovascular disease. But the conclusion of the study that there was increased bleeding and that overshadowed the benefit in reducing cardiovascular disease. This is a place, though, where you might want to use that shared decision-making for the 40 to 59-year-old person with diabetes. Because on one hand, bleeding tends to be a temporary event. Even bad cases, people show up to the hospital, we tend to get it stopped, and they go home. If you have a heart attack, you can have more permanent damage or stroke. So that's what you have to use as a trade-off. But then this ASFRE study was really important. In adults over 70, the intervention group randomized to take aspirin was more likely to die. So the number needed to harm was 143 people taking an aspirin increased one death. And it was due to cancer deaths, as well as bleeding, but primarily cancer deaths. And the cancer deaths were GI cancers, which was strange, because the prior recommendation, if you remember, was about aspirin preventing both colon cancer and reducing cardiovascular events. That's why it was 40 to 49. It was a B, because you could prevent colon cancer, as well. So with this late update, the task force took out prevention of colon cancer. There is some data that aspirin might prevent colon cancer, but this ASFRE study raised a question as to whether that's true in this current era of screening and just risks in general. So this got the task force to change the recommendations to selectively offer it to people 40 to 59 and to not do it. The D for people 60 and older, your bleeding risks go up, and then you have more strong evidence with this ASFRE study about people dying who are older for primary prevention. Okay. Now we're going to transition from cardiovascular disease to talk about respiratory disease. So I have three main topics here for respiratory disease. The first one is COPD, or chronic obstructive pulmonary disease. This was updated by the task force in May of 2022. It's not different than prior recommendations, but it's a little bit different. It's a little bit different than prior recommendations. It's not different than prior recommendations, so this has been consistent throughout. And it's a D to screen asymptomatic adults for COPD. This topic also is largely a D because COPD tends to be a symptomatic condition. Asymptomatic COPD is not necessarily significant, at least looking at the evidence from a standpoint. The problem is much more about when people start experiencing symptoms, and that's when you tailor treatment to symptoms. So there's not really much to do for asymptomatic COPD. Now we still should have a big focus on preventing the development of COPD. 90% of cases are due to smoking, so the way we prevent COPD is to get people to quit smoking. So in people who have COPD, we have a focus on preventing exacerbations and improving the quality of life, but this leaves prevention and gets much more into condition management, hence the D for screening for asymptomatic COPD. The next topics to talk about is sleep apnea. So this was updated in November of 2022. It was also done, I think, in 2016. Both times, it's an I, where the U.S. Preventive Services Task Force said there's insufficient evidence to recommend for or against screening for sleep apnea. So this is the general population, and this is screening. So this is checking people who don't have signs or symptoms. This is not about treating people with sleep apnea or doing tests on people who have symptoms. And sleep apnea is very common. So the prevalence of it is somewhere between 2% and 14% in different studies back in 2013. Sadly, obesity has gotten worse in the United States, so I suspect that COPD actually is more prevalent now than that 2% to 14% than it was. You extrapolate it at least over time, we're probably closer to 16%, maybe even higher. And there's a lot of adverse outcomes associated with sleep apnea. So everything from being more likely to die, to have cardiovascular events, car accidents, cognitive impairment, missing work, decreased quality of life. So true COPD makes people tired and it affects your quality of life. It's partly where we get a little bit to the eye and where we start thinking about screening and what is the value of detecting sleep apnea in someone who has no signs or symptoms. They're not tired, they're not reporting any issues. There are 63 trials. So the other bit to think about, though, too, is the treatment. So what is the benefit of treating screen-detected people? The task force looked at 63 different trials on treating sleep apnea, everything from using CPAP, the continuous positive airway pressure, to surgery or other types of interventions. Most of the patients were identified in sleep clinics or referrals, so probably not a screen-detected population. There weren't any in primary care setting. And the treatments of all these trials is just for under 12 weeks. So in these randomized control trials, they randomize people to CPAP or sham CPAP, follow them for 12 weeks. And these are people who have apnea hypopnea indexes, AHI, of more than 30. That means they stop breathing or breathe very shallow 30 times in an hour. So they're pretty significant sleep apnea. And the main benefits of these trials is it reduces that apnea hypopnea index. It does improve daytime sleepiness, and it improves systolic blood pressure by one to two points. But that wasn't enough to say that for the task force that there's evidence that treating folks with screen-detected sleep apnea would result in an improved health outcome. If someone's sleepy, completely different thing. Smoking cessation, this was updated in 2021. There's a long history of recommending screening and counseling for tobacco use in adults. So it's an A for clinicians to screen all adults and provide tobacco cessation interventions. It's an A also for pregnant women. Pregnant women are carved out separate for two reasons. One is it's actually a window of opportunity, and the evidence suggests that smoking cessation interventions are more effective for people who are pregnant. The other thing is the treatments are a little bit different. So it would be a focus on counseling as opposed to medications. It was insufficient evidence to recommend pharmacotherapy in pregnant women. That's actually kind of called out in the top lines now. And it was insufficient evidence to recommend electronic nicotine delivery systems for tobacco cessation. So for kids, it's a B for counseling kids about tobacco use. So you'll notice adults is about screening for smoking tobacco, and kids is about counseling for tobacco use. And it's a B for school-age children and an I for adolescents who use tobacco. I want to unpack two things with these recommendations. So a big reason why going back here to the vaping or electronic nicotine delivery systems being an I for tobacco cessation is because there is data that you can get people to stop combustible tobacco and switch to vaping. But at the end of a year, two, three years, something like 80% of people are still using the ends at the same rate as when they made the transition. So there's a concern about you're really just switching one unhealthy substance to another unhealthy substance. So I think if we could get some evidence that it gets people off combustible cigarettes, and then they switch to vaping, and then you can get them off of vaping easier, and we can get more people to quit, the task force could get off of the I. But I think until then, this is just a hypothetical thing. And for kids, most of the evidence is on these different school-based interventions where we go and do counseling in schools, tar wards and other things to teach kids about the harms of smoking and to not start smoking. And that's the type of evidence that got the task force to a B for counseling children about not starting to use tobacco. You should know the basic counseling and behavioral technique literature. So we have the five A's. This is a very important concept around health behavior change. It's about ask, advise, assess or agree, assist and arrange. So depending on where people are, if they're ready to quit, you ask, find out if they're using this, give them some brief advice. You're assessing their willingness. And if they are willing, that's when you provide the assistance and arrangement to help with quitting. And I think in the healthcare system, we do okay with the first three A's. We don't do very well with the last two A's, particularly with more intensive health behavior changes like diet and exercise. A4, getting assistance, helping people to quit, at least for tobacco. This is like quit plans and practical counseling, motivational interviewing, recognizing risks and pitfalls of going back to smoking, developing coping skills, building a social support network, those types of things. So that's what A4 is. And you can apply that to any health behavior change, whether it's unhealthy alcohol use, diet, exercise, or smoking. The other concept to know is the five R's. So a patient or person who says, yeah, I smoke, but I'm not really ready to change right now. The five R's is a tool to try and enhance motivation to get people to make a health behavior change. So it's the relevance, why is this important for you? The risks, what's the problem for you if you continue to do this? What's the reward? You'll be able to exercise more, you'll live longer, whatever the rewards are. What are the roadblocks? Why don't you want to quit right now? And then repetition. So I've been in my practice now for 25 years, and all my patients who smoke have heard me talk about this many, many, many times. And I have found that it may be one, two, three, five, 10 years before someone's ready to quit, and they're not quite ready to quit. But it may be one, two, three, five, 10 years before someone's ready to quit. And at least for me, that's the strength of longitudinal relationships in our healthcare system. There are other smoking cessation options. So you have the first line pharmacotherapy, nicotine replacement, bupropion, baronicline, or Chantix. You have the second line therapy like clonidine and nortriptyline. They're quit lines. There's lots of practical information from the surgeon general. There's other things that can try and help people. I suspect cognitive behavioral therapy would even help some people in some cases. In counseling, I talked a little bit about this. You know, high school students, unfortunately, the tobacco use is going up a little bit. Even more so though is the e-cigarettes. In education and counseling does reduce the chances children and teens will start smoking. So the task force was very mindful when using the word of tobacco use. That would include combustible tobacco, would include e-cigarettes, but most of the evidence was about tobacco and not other non-tobacco related products that you might use electronically. And these interventions can be direct counseling, can be videos, apps, print materials, guides, workbooks, pre-printed subscriptions, all those things work. All right, let's transition to cancer. So there's a lot of different preventive service recommendations around cancer and screening for cancer and medications to prevent cancer. And we'll talk about those. And then later we get to the health behavior change, you know, doing things like not smoking, being careful with unhealthy alcohol use, eating right, exercising, those also reduce cancer. So think about that as you're looking at the questions that they're asking you for the boards. Cancer is the second leading cause of death. About one out of four to one out of five people will die from cancer. If you're looking at incidents, prostate for men and breast is the number one cancer in terms of common. If you get asked this question, look at it carefully because they would, if they say the most common non-skin cancer, it's prostate for men and breast for women. They don't include skin cancer and skin cancer is one of your choices. That is the most common, particularly when you get the squamous and basal cells. The number two for incidents is lung cancer. And the number three is colorectal cancer. And then if you're looking at the number one causes of death, overall lung cancer for both men and women, prostate is number two for men, breast number two for women, colorectal is number three. If you have a question where they say, what's the overall, including both men and women, it's lung number one and colorectal number two, because prostate and breast only occur for half of the population. So it's just a little less frequently. So let's delve in first to cervical cancer screening. Here's a topic that you're going to need to look at what guideline they're asking you about. So the task force did its most recent recommendation in August of 2018 and gave an A to screen women age 21 to 65. And women is defined as people with a cervix and recommend screening for cervical cancer every three years with the pap smear alone for 21 to 29 and women for 30 to 65 a pap smear alone every three years or the HPV test alone every five years or the HPV test with the pap smear known as co-testing every five years. Now I'll just put a little historical context here. Even now the HPV test is harder to get as a single test, but in 2018 it just wasn't terribly available, which is partly why the task force included co-testing. And you'll see some contrast with some other recommendations here. It's a D for women over 65 who have had adequate screening and they can stop screening for cervical cancer. It's a D for women under 21 and it's a D for women who had a hysterectomy for non-cancerous or precancerous reasons. I would definitely ask a board question that delved into the who not to screen type of questions. So these are cohorts you should know about. So the task force in their update in 2018 did kind of raise this concern about adequacy of screening for people over the age of 65. So they do define adequate as, you know, two prior tests that have been negative. Their most cervical cancer deaths occur in women who have never been screened or who had inadequate followup after an abnormal screening test. So those are really the concerns that you have for reducing mortality. And so women over 65 who haven't been adequately screened would be a cohort to think about doing some screening before you told them they didn't need any more. The other focus for the task force was about adding in the primary HPV testing as a screening modality. That was new in 2018. So the task force found direct evidence about HPV testing versus cytology alone. There were three RCTs and, you know, one to two rounds of screening. Screening intervals very focused on CIN3. Fortunately, most women don't die from cervical cancer these days. And either of these was effective. Also looked at co-testing versus cytology alone. There haven't been a whole lot of tests of co-testing versus just HPV alone. And that's actually where the task force did some overall modeling, which I'll show you in a second. But screening with cytology alone is less sensitive for detecting CIN and CIN3 than screening for HPV testing alone or co-testing. But HPV testing alone or with co-testing does result in more diagnostic colposcopies for each case to test it. So the way to think about it is you're gonna have a few more false positives and some more colposcopies with the HPV testing. You get to do it less often, i.e. every five years, which is a big advantage. And I just kind of focus in on that. These are all effective, adequate screening methods and approaches. Here's some of the numbers of cancer cases, CIN3 cases detected, life years gained, number of colposcopies. And you can see, looking down there, the life years gained are pretty much equal with all these different screening approaches. The draft the task force originally had recommended just cytology or HPV. That came out in the draft. And there was a bit of an outcry on the public comments that you couldn't really do HPV alone in 2018. So the task force added colposcopy back in. And I think the big reason that the task force had focused on just HPV alone is because you see that there are less colposcopies required likely than with co-testing, which might have a few more false positives than the HPV alone. So that's an advantage. This is where you gotta read the question though. So the American Cancer Society recommendation says that women 25 to 65 should have a primary HPV test every five years. So they don't recommend screening until 25 and only HPV. So if you follow the task force, you wouldn't do an HPV test until 30. If you follow the American Cancer Society, you can start HPV at 25. They do go on to say if primary HPV testing is not available, then you can think of either co-testing or cytology alone. They do highlight as well that women over 65 who've had regular screening in the past 10 years with normal results and no history can stop. And people who've been vaccinated for HPV should still follow these guidelines. We'll see what happens over time as the vaccine, more people have gotten the vaccine. We'll see if we still need to do as much cervical cancer screening. But for now, it doesn't change what you do in terms of screening. As I mentioned, implementation is key. Most deaths are in women with inadequate screening or inadequate follow-up. So if we wanna reduce deaths from cervical cancer, that's what we have to focus on. The adequate screening before stopping at age 65, normally three negative pap smears or two negative co-tests or HPV tests. So if you're asked a board question, that's where you'd kind of concretely define adequate screening. Pelvic exam. The task force looked at pelvic exam for anything. Like as a clinician, if you do a pelvic exam, it's to look for cancers, it's look for infections, it's looking for multiple different things potentially. So it's a very broad category in this context. And I think because it was such a broad category, the task force ended up with an I statement. So if you try to think any potential benefit for pelvic exam, there isn't any clear evidence, but there could be evidence depending on what you wanted to think about. So that's where the task force said, well, it's insufficient and we're not gonna give it a D. But we'll talk later. There is actually a D recommendation for pelvic exam to look for ovarian cancer. So that does not help women. So if that's the reason you're doing a pelvic exam, you shouldn't do the pelvic example. Colorectal cancer screening. This was updated in May of 2021. I don't know what they're gonna ask you about this. The difference from May 2021 versus before is the age to start. That's the thing to know. I'd like to think that they could change a board question between May of 2021 and the fall of 2023 here. So I'm gonna present the 2021 guideline, which is it's an A for screening all adults age 50 to 75 and a B for screening adults age 45 to 49. So read the question. If you see that it says, according to the 2016 US Preventive Services Task Force, when should you start screening? The answer is 50. If they don't clarify and they give you options of 45 and 50, I would pick 45. And if they say the 2021 task force, I would definitely say 45. And it's a C for screening adults 76 to 85. And really the clinician should consider the patient's overall health, prior screening history and preferences. When you look at the evidence, it takes about 10 years to die from colon cancer when it starts. So people over 75 with a less than 10 year life expectancy really shouldn't be screened. That's a difficult conversation to have with a patient. I don't say, I don't think you're gonna live 10 years, we shouldn't screen you. More what I'm thinking about is asking people, well, what would you do if it were positive? So if you had a positive screen, if you've got cancer, the treatment is a colectomy, having part of your colon removed. And maybe even needing a colostomy and maybe chemotherapy. So would you be willing to do that? That's a much easier conversation with patients. And a lot of people 76 to 85 say, doc, if I had that, I wouldn't wanna do anything. And that's great, that's when you stop screening. The lifetime risk of getting colorectal cancer is about 4%. Chance of dying from colon cancer is about 2%. Advancing age is the biggest risk factor. Black and Native American people are more likely to have and die from colon cancer. Other risks are obesity, diabetes, smoking, unhealthy alcohol use and family history. And the average person who dies from colon cancer lives 13 years less than someone who doesn't die from colon cancer. Now, most important to know is most colon cancers occur in normal risk people, 80%. Only 20% occur in high risk people. So this is why it's so important to screen everyone. It doesn't matter what your risks are. But 20% are in high risk people. This is like a family history of a first degree relative with colon cancer, prior large adenomas polyps, adenomas polyps before age 60, ulcerative colitis, some uncommon genetic conditions. But most occur in average risk people. So from the task force standpoint, there are four key messages. Colorectal cancer screening saves lives, get screened, start screening at age 45. There's more data showing the rate of colon cancer in a 45 year old is similar to that of a 50 year old. That's why the age moved down and that was from modeling studies. And there's several tests that can effectively screen. So this is like your stool based tests, like your FIT or your Cologuard, or your visualization tests like the colonoscopy, the CT colonography, or the sigmoidoscopy. And they all have kind of pluses and minuses. And black adults get colorectal cancer more often and they're more likely to die for it. So it's particularly important to screen black adults. These are the different screening options. Stool test for blood. These are an annual test. The stool DNA FIT test every three years, the CT colonography every five, flex sig every five, or flex sig every 10 with an annual FIT, or a colonoscopy every 10. That flex sig every 10 with an annual FIT, it's kind of weird because you say, well, an annual FIT, isn't that already a screening? Why do you need the flex sig? It may approach some of the, it just, it's for patients who want some visualization and it may approach some other benefits similar to a colonoscopy. So the task force did not look at the blood or urine tests. I don't think there are any guidelines recommending those. So if you have a question, should you do a blood or a urine test? The answer is no. There is emerging evidence around this and we'll need to figure out where this fits in, but it's not mainstream right now. And just know that like the stool based tests have a different set of barriers than the visualization tests. So really a message for people is the best test is the test that you'll get. Here's some of the data that shows you about how the risk of colorectal cancer at age 45 is similar to a 50 year old in the past. You see these different cohorts of people over time and the rate per 100,000 of dying from colon cancer. And it's really nice to see, if you look at the age from 55 and older, really there, the deaths have been going down steadily for colorectal cancer. I like to think this is because we're improving treatment and screening. But if you look at the younger cohorts, age 50 and lower, the rates are going up. And that was a driving factor in the task force lowering from 50 to 45. Here's some of the modeling data about the life years gained. And the first column is if you start at 50, the second column is the additional life years if you start at 45 instead of 50. So it adds about 26 extra life years if you start a little bit earlier. And you can see there the life years gained if you start at 50, it's pretty similar across these different screening strategies. Really the 306 for the sigmoidoscopy and FIT every year and the 310 for the colonoscopy every 10 years, it's pretty much the same number even as the 292 for the FIT test. Now, if you go from 310 to the 278 of the FIT test every three years, or the FOBT every year of 272, those numbers might be significant in their differences. But for the most part, all these strategies are effective at preventing deaths from colorectal cancer. Now, here's the trade-off, the number of lifetime tests that you'll need to get with the different screening strategies. And all of this is in the task force recommendation. If you go to the very bottom of the page on colorectal cancer, there's a tab for figures and all these are part of the figures that are there. And you do see that depending on your screening strategy, you get more lifetime tests. So as an example, if you do the stool DNA and FIT test, you'll have 2,221 lifetime colonoscopies for a thousand people being screened, versus if you do the FIT test, you only have 1,497. At least for me as a clinician, I tend to do the FIT test and offer that to patients or the colonoscopy. In my community, we don't have sigmoidoscopy. No one does those. And I sort of, in my experience, most of my patients, the reason they want a stool test is they don't want the colonoscopy. So I don't like the trade-off of more colonoscopies of the DNA FIT test over time. But that's a personal thing. I think for your boards, all of these are equal at saving lives. And then it would be reasonable if they asked you, does a DNA FIT test have more false positives than the FIT test? The answer would be yes, in terms of lifetime colonoscopies. But there's a lot of similarities here. You can see the lifetime colonoscopies, if you screen with a colonoscopy, is 3,464. So, you know, these different screening methods have different barriers, and the best test is the one a person will get. I'm gonna share with you just a little bit about the multi-sitey guidelines. The task force doesn't get into like these family histories, but if you have a family history of a first-degree relative with colon cancer before the age of 60 or two first-degree relatives, you would start at age 40, you'd screen every five years, and you'd only offer a colonoscopy. And if you have a first-degree relative with colon cancer over the age of 60 or two second-degree relatives, you'd start at 40, and you can do the interval the same as normal risk, and you can offer the same test as normal risk. So a lot of clinicians think, oh, you know, if you have a family history, you have to have a colonoscopy. Well, it's not exactly true. It's a family history of a first-degree relative diagnosed under the age of 60. So I would ask a question like this because I think family history is common enough that I think this is fair game for preventive medicine boards. I think it's also fair game to talk about polyp management. 80% of colon cancers arrives from adenomatous polyps. Most are not gonna progress to cancer. So less than 1% of ones less than a centimeter will progress to cancer, and that's if you don't remove them. If they're above a centimeter, that's kind of a cutoff where we worry because those are a little more likely to become cancerous. And what you see is that about 20 to 25% of 50-year-olds will have an adenomatous polyp, and 50% of 75-year-olds have an adenomatous polyp. That's why I say this is in the realm of prevention. So there's a substantial proportion of people who have polyps, and so following up on the colonoscopy is important. So if patients have a hyperplastic polyp, you treat that the same as a normal colonoscopy. It's no different. It's basically just normal colon mucosa that's just formed a polyp. If they have one or two small, low-grade adenomas, the guideline, it actually used to be repeated in five to 10 years, and just in 2019, they changed it to seven years. It's all expert opinion. There is a randomized control trial that randomized people to get, in this cohort, to get a colonoscopy every five versus every 10 years, and I haven't seen the results published yet, but it will be coming out. But for right now, this is just based on our knowledge that polyps can become cancer, and people who have polyps are more likely to get polyps, so maybe it's beneficial to screen them more frequently, but maybe not. We don't know, and that's where, in 2006, they said every five to 10 years. The reason they changed it to every seven years was because most doctors operationalized the every five to 10 years by just doing it every five years, and that's not the intent of the guideline, so they split the difference and said every seven years. I think for you, what I would be looking at, if I were to ask a question on the boards, it would be like someone has one or two polyps, and I would say something like they have to get a colonoscopy every five years or every three years or something, I would say too frequent of an interval and have that be an incorrect answer. I don't think they're gonna split hairs as to is it five to 10 or is it seven years, but that's where we're at, and we'll see where the guidelines go. And then if people have three to 10 or one big adenoma or high-grade dysplasia, this would be when you do it in three years, and then if that's normal, you do it every five years after that with a colonoscopy. In terms of colon cancer chemoprevention, so we used to, the task force used to kind of recommend aspirin. It was built into the 2016 recommendation, but I just shared earlier with the ESPRIT study that that's not really true. So aspirin is not really something we think of for a medicine to prevent colon cancer, and there are no other medicines, but eat right, exercise, don't smoke, be careful with alcohol, watch obesity, all those things can reduce colon cancer, those risk factors I shared. So this is the task force recommendation for prostate cancer screening. This was in May of 2018. The task force recommends a C, selectively offer prostate cancer screening for men age 55 to 69, and there's a lot of language in this top line, which is really just outlining shared decision-making in saying that before being screened, men should have a chance to, opportunity to kind of discuss the potential benefits and harms of screening, think about their risks, know about the small potential benefit of reducing death and the trade-off of many men experiencing potential harms such as false positives, possible biopsy over diagnosis over treatment. So this is really outlining shared decision-making, and then the task force gives a D for routinely screening men 70 and older for prostate cancer. American Urologic Association's actually pretty in agreement with this. So they recommend against screening men under 40 or over 70, and they recommend not screening average risk men 40 to 54, but maybe individualizing for men at increased risk. So if they're presenting a patient who's 45, has a family history of prostate cancer, that type of a thing, I'd read the question closely. If they say, should you do shared decision-making with that person, it's not unreasonable. If they say, does the U.S. Preventive Services Task Force recommend shared decision-making for a 45-year-old with a family history, I would probably say no to that. The American Urologic Association says for men 55 to 69 to do shared decision-making, I'll make the C for the task force. And they also recommend screening every two years for men who decide to be screened, just like the U.S. Preventive Services Task Force. They do have a little caveat and say, some men in excellent health may benefit from screening over 70. Over 70 is interesting. There's not a bright line to say at this age you stop. The task force looked a lot at modeling, and it did look like around 70 is when you start to have much more indolent prostate cancers that are never gonna affect men. So your risks of over-diagnosis go up, and the complications from surgery and treatment start to go up so that your benefit and harm ratio really start to look less and less favorable above 70. So it's not just how long you'll live, it's the type of cancer you might have, and also the type of complications you might have from treating your cancer that create that stop screening at 70 recommendation. So as I shared, it's the second most common cause of cancer deaths in men. Lifetime risk is about 10, 11%. It does depend on whether men are screened or not. So in countries where men don't really opt for screening, the risk of prostate cancer is much lower, but that's because we're not detecting all these cancers. 75% of people with prostate cancer die at 75 or older. That sounds confusing, because the task force gives you a D for screening at 70. But remember, prostate cancer often takes 10, 20 years to kill people. And this next statistic, black men, their chance of dying from prostate cancer is 4%. So it's double the general population. And then family history, this is where if they're presenting a risk scenario, I'd read it really carefully. Family history does increase your risk, but you have to be careful what the family history is. So often I'll see patients and they'll be like, oh yeah, my dad had prostate cancer. And then you delve into it and it's like, well, my dad was screened at 85 and they diagnosed him with prostate cancer and he died at 95 from heart failure. He essentially did not have a family history that puts that patient at a risk. So it really depends what you're talking about. A family history where a first degree relative died of prostate cancer, particularly if it was a younger age, that's significant. A family history where it's a second, third degree relative, older age, indolent type cancer, maybe that doesn't mean anything. Several trials are on this. The big one is the European randomized study. That's what the task force used and the American Urologic Association used. It includes seven countries, 160,000 men. They're randomized to a PSA every two to four years. There were different countries and they had slightly different protocols, like what level's a high PSA and how often do you get screened? So there's some limitations with that, but the strength of this study is the control group had very low rates of men getting a PSA test. I mentioned earlier the PLCO trial for men in the US, 76,000 men. The big limitation is more than 80% of men were non-Hispanic white. I think there was only 4% black men in this trial, which was just terrible. That's a group that should have been recruited better for this study, because these black men are the exact people that we wanna know if this is gonna help the most. And as I mentioned earlier, the control group had very high rates of getting a PSA test at some point. There was another trial in the UK where they mailed almost half a million men an invitation to get a PSA test. The big limitation is only about a third of those men got a PSA test. It was a one-time mailing. So it's really hard to tell what that data shows us. But if you look at all this data and you look at the pure intention to treat trial data, if you're in the screening group, you're more likely to be diagnosed with prostate cancer. So you get prostate cancer, you have a higher incidence. The European trial did show a reduction in metastatic disease with screening, neither CAP nor PLCO, they didn't report that. And mortality reduction was only significant in the European trial. The CAP trial didn't, and the PLCO didn't. PLCO might be contamination, CAP might be one-time screen. It didn't affect all-cause mortality, which is not unexpected. And the harms of screening is false positives. So about 15% of men will have a false positive. And a lot of times we end up doing biopsies on men with a high PSA. That has a 1% risk of complications like pain, bleeding, infection, resulting in a hospitalization. And then there's over-diagnosis of cancer. So this is a cancer that'll never grow, never spread, never cause harm. We only find out about it because we did a PSA test. And that's about 20 to 50% of screen-detected prostate cancers based on the trial data from the European study. Here's the harms of treatment, incontinence, erectile dysfunction, surgical complications, even death. The death data, that's three in 1,000 is probably on the high end. That's from older 90s and 2000 data. We've gotten a lot better. But the issues of incontinence and erectile dysfunction are pretty common for men. This is the infographic the task force put together. If I asked a board question, I would say something around this. You know, 1,000 men are offered a PSA test. You'll prevent one to two from dying from prostate cancer down there at the bottom. You'll prevent three from getting metastatic disease. Five still go on to die. So six out of 1,000 in this scenario die over 15 years and you'll prevent one death. And then the trade-off is that 240 men will have a positive result at some point in time. Many will get biopsies. About 100 will be diagnosed with prostate cancer. About 20 to 50% will be over diagnosis. And about 50 men will have erectile dysfunction and 15 urinary incontinence. Don't get too hung up on the exact numbers. You know, you need to know kind of more generally one to two men out of 1,000 will die. Three will not get metastatic disease. Five still die. About one in four will have a positive result. About one in 10 will be diagnosed with prostate cancer. And about 80 of those end up going on to have surgery. You can do active surveillance, but a lot of active surveillance does at some point convert to surgery or radiation. So task force couldn't say about men at increased risk. We looked very closely at black men and could we look at any of the data. European trials included countries like Norway and Sweden and had very low rates, unrecorded rates of black participants. The U.S. trial, as I said, only had 4%. So there's just no way to really get at this type of a data. And then same with family history. You know, as I mentioned, it's very specific family history that we're more worried about. There's not enough data on this, but it is embedded in that C recommendation for men 55 to 69. So talking about an individual person's risks about being a black man or having a family history should be part of the discussion and should be part of the shared decision-making on whether to be screened or not. I already mentioned the data on men 70 and older, more likely to have complications, more false positives, more over-diagnosis, more medical complications and mortality after prostatectomy. So I'll have patients that are coming in and seeing me, I've been in my practice 25 years, so many of my patients are older and they're like, Doc, you know, are you discriminating against me because of my age? The answer is absolutely not. It really is about the shift of the benefits and the harms and the harms go up. It's about all of the harms of the false positives, the over-diagnosis and the complications. It's not just about how long they'll live. That really creates that cutoff above 70. Lots of research needs and gaps, looking at these high-risk people, black men, family history. We also, you know, I think a lot of the data, if you look at that flow diagram around the PSA test, it's just not a good test. And I think it's reasonable to know that the PSA is not a very good screening test and we need better screening methods and tools to really be able to do this better. There's emerging science like MRIs and other things, but those are not routinely recommended for screening and are just beginning to be part of the follow-up process for differentiating high PSAs that are significant versus not significant. Chemoprevention, or we really changed that word. I need to change the slide. It should say medicines to prevent prostate cancer. Chemoprevention sounds very ominous. There are ones that have been studied, finasteride, vitamin E, and selenium. And the answer is that none really have been shown to be beneficial. Finasteride can lower your PSA, but when cancers occur, they might be more aggressive. So by lowering the PSA, we might biopsy less men. So maybe it decreases incidence because of lower PSAs, but maybe it does prevent low-grade prostate cancers. We're not really sure, but there's no mortality change in the trials. And the vitamin E and selenium, vitamin E in the select trial actually increased cancer and selenium increased diabetes. So these are not medicines to prevent prostate cancer. Long message short. All right, let's move and talk about breast cancer now. We'll start with breast cancer screening. The task force, I think you're gonna be tested on the 2016 recommendation. That's what your test will be. You probably know that there's a draft recommendation from 2023 that just came out. Draft recommendations are drafts. So not even the Affordable Care Act links coverage to a draft recommendation. So it hasn't been finalized. So you're not gonna be tested on this. You'll be tested on the 2016 recommendation, which was B, for getting a mammogram every two years for women 50 to 74. C, on whether to start early, i.e. 40 to 49. It should be an individually tailored one. And I, about insufficient evidence to assess the value of screening over 75. If you read the recommendation though, this is not saying to screen women forever. It does say that there is data about breast cancer that similar to colon cancer, women who have a life expectancy under 10 years are not likely to benefit from breast cancer screening, but the exact age to say that that means we should stop is unclear. That's what the I means around that. And an I to recommend for digital tomosynthesis, this is your 3D mammograms. So if you see questions like all women should get a 3D mammogram, no, no, it's, we don't know actually. And then for women with dense breasts, should we do anything different? It's an I. So we'll talk, but women with dense breasts are more likely to get breast cancer. And so that's a risk factor, but we're lacking evidence to say because we know a woman has this risk that we should do anything different. All right, and, oh, here, this is important. We said in 2016 that we didn't update the 2009 recommendation on breast self-exam, but in 2009, we said there was, it was an I insufficient evidence to recommend clinical breast exam or breast self-exam. Taskforce supports women being aware of changes in their bodies and discussing these changes, but this idea of teaching women a self-breast exam, this probably does not impact mortality. Breast cancer is the most frequently diagnosed cancer and second leading cause of death in women for non-squamous cell cancers, non-skin cell cancers. The biggest risk is age, it goes up as you age. And the good thing is the incidence and mortality of breast cancer actually are decreasing. Even with the current update and recommendation to start screening women, and recommendation to start screening women at 40, we're still seeing that breast cancer overall is decreasing. The current task force thought that the incidence of breast cancer in younger women, 40 to 49, was going up, like with colon cancer, and that black women are more likely to get breast cancer and die from breast cancer, and lowering the age to screen closed some of that disparity, which is some of the reasoning for lowering the age to 40. And it's not lowering in the context of anything. The task force in 2016 still recommended screening at 40 to 49, but it was selective screening in women who wanted to be screened and balancing the benefits and harms. So it just switched from a C to a B for 40 to 49. All right, so a lot of trials were included in the 2016 review and the 2023 review. And one of the challenges with looking at this data, just so you know, this is an interesting issue, is that if we rely on the screening trials, like the pure randomized control trials, these are now 20 to 50 years old. So they're pretty outdated, but they've included lots of women in these trials, you know, more than half a million women. So this is our highest level of evidence. We've got, you know, the least amount of bias in these studies. However, you know, they don't reflect more recent changes, some of the technical changes in the tests, the treatments, the breast cancer risk factors that have changed for populations. The observational evidence, which is also included in the task force recommendations, you know, has the strength of being a little bit more up-to-date and more recent, but these studies have a lot of biases, like lead time bias, length time bias, healthy volunteer bias, these observational studies. So it really is kind of trying to look at both of these sets of evidence and putting them together to make decisions. In 2016, here was the breast cancer specific mortality. Once again, I don't think you need to know these numbers per se, but what I want you to know and to see is that your chance of dying from breast cancer and the reduction of death in breast cancer with mammogram, you know, the reduction of death goes up as you age. So women as they age are more likely to get breast cancer, they're more likely to die from breast cancer, so they're the greatest benefits. And if you look even at that 39 to 49 in the old original clinical trials type data, the women who were younger than 50 in those, you can see that the confidence interval crossed one and it was potentially not statistically significant depending on how you look at those trials. There are risks of over-diagnosis with screening. So it's about 11 to 19% of women will be over-diagnosed. And so a way of thinking about this, for every woman who we prevent a breast cancer death, two to three are diagnosed and treated for a breast cancer that was not destined to harm them, that's the over-diagnosis. So that's sort of the harm and the trade-off of some of the breast cancer screening. And here's more of this data put together. And what I think I want you to see, once again, you don't need to memorize these numbers or I wouldn't memorize these for your test, but I think what's important to know here is that false positives are more common in younger women. So as women age, the breast tissue gets replaced more with fatty tissue, the mammograms become a little bit more, their specificity improves and your false positives start going down. Your biopsies are still about the same, needing to get biopsies, but some of that is because as women age, they're more likely to have real abnormal findings, so they need a biopsy. The younger age women are gonna have more biopsies that you could argue were not necessary, i.e. they do the biopsy and don't find anything that's abnormal. And you can see the false negative mammograms, it's a low rate and it's pretty consistent throughout. This is the draft for 2023. As I said, the major change resulting in this was adding modeling to look at the data and lowering age improves equity for black women. And that's valuable. I think the issues of kind of the harms are not really different. So the evidence is not dramatically different from 2016 to 2023, other than the task force took this equity lens of looking at the data. So I do think there's still an element of talking with women and making sure under 50 that they do know about some of the potential harms and guidelines or recommendations. So at least personally, I still think there are some women under 50 who may choose to not be screened and that could be reasonable. Clinical breast exam, as I mentioned earlier about it, task force doesn't routinely recommend this. There are three trials from developing countries. And the whole idea was, here you have these developing countries where women don't have access to mammograms. This is the place you can prove that doing a less technological resource intensive test like a clinical breast exam might actually show benefit. And it didn't. It did increase findings of abnormalities and doing tests and biopsies had no influence on changing breast cancer more. So no mortality, no. Same thing with breast self-exam done in Russia and China. Once again, more biopsies, slightly more diagnoses, but no reductions or changes in mortality, which partly leads the task force to give these eyes and not necessarily recommend them routinely. Here's the American Cancer Society recommendation from 2015. It says women 40 to 44 should have a choice about when to start. So that shared decision-making. Women 45 to 54 should have a mammogram every year. Women 55 and older should have a mammogram every other year. So this is somewhat similar to the task force guideline from 2016 with this kind of weird thing for women 45 to 54 and a mammogram every year. It's not unreasonable to just kind of know that the American Cancer Society and the task force are somewhat in agreement here with some slight differences. You know, there's big consensus, women 55 to 75 mammogram every other year. The every other year has most of the same benefit in reducing deaths from breast cancer with the trade-off of reducing the harms from over-diagnosis and over-treatment and false positives. They also cite lack of evidence on the breast exam and the clinical breast, the self and clinical breast exam. They do talk about MRI and women who have a very high lifetime risk above 20 to 25% of BRCA mutations or first degree relative with a BRCA mutation or having radiation. These 20 to 25% lifetime risk is a pretty high risk. So these are high risk populations for mammogram, for MRIs, for screening for breast cancer. So if you get a question along those lines, it wouldn't be unreasonable. The task force, US Preventive Services, is not talking about this type of high risk group. So this is a place you'd look to the American Cancer Society. And they do recommend against MRI for women whose lifetime risk is below 15%. And they're a little bit unsure about 15 to 20%, sort of their equivalent of an eye. So let's talk about medicines to prevent breast cancer. So the task force does recommend that women 35 and older offer to prescribe risk-reducing medications. This is tamoxifen, riloxifen, aromatase inhibitors to women who are at increased risk for breast cancer and low risk for adverse effects. And a D for women who are not at high risk for breast cancer. Tamoxifen and riloxifen would be medicines that you do for premenopausal women. You can't do aromatase inhibitors for premenopausal women. Aromatase inhibitors you can offer for post-menopause. Generally speaking, tamoxifen and riloxifen have a lot more side effects. Aromatase inhibitors are lower. And so that's sort of the distinction on that prevention. Big trial showed tamoxifen and riloxifen reduce breast cancer incidence by 50% in high-risk women. This was the STAR trial. Does increase your risk of thromboembolism, stroke, endometrial cancer. Has a lot of symptomatic side effects. The tamoxifen has more thromboembolic events where riloxifen is lower. But the benefits are thought to exceed the harms in high-risk women. And this is usually going and calculating a GALE score in that they have a risk of 1.66 or above. The GALE models like on this NCI website where anyone can access and calculate it. And it's a very common way in practice to think about identifying women who might benefit from this is women in their 40s and 50s who are first degree relative with breast cancer, they might be appropriate to calculate a GALE score on. So you can also think of other populations for higher risk for breast cancer. So Ashkenazi Jewish women, women who have many family members with breast cancer, maybe women who have family members with ovarian cancer or male members with breast cancer. Those are some of the things you might be thinking about. Although that also is getting into this, which is looking for hereditary breast cancer. So the first one, when we talk about medicines to prevent breast cancer, this is a woman's overall risk for breast cancer. So this includes things like when your periods start, when you go through menopause, how many kids you've had, whether you breastfeed, some of your health behaviors, as well as your family history. So BRCA is really getting at your genetic risk for breast cancer. And so the task force gives a B recommendation for women with a personal or family history of breast, ovarian, tubal, or peritoneal cancer, or an ancestry associated with BRCA gene mutation. And it's a D recommendation for women who really are not at increased risk. Now, we all know that anyone now can go and they can do 23andMe and these other tests and you can get your BRCA. You don't need to go to a provider. More often providers are having to help patients think through what these tests mean. But I would argue that it's better to think about what you do with the test results beforehand because this can cause some harm for women if they're not really prepared for doing this type of a test. So the examples of women who would be at higher risk for a BRCA related cancer, two first degree relatives, one diagnosed before 50, three or more first or second degree relatives, first degree relative with bilateral breast cancer, a male relative with breast cancer, two relatives with ovarian, Ashkenazi Jew, Jewish person, or with a first or second degree relative with breast or ovarian cancer. All right, and then getting back also to that discussion about having women think about what they would do with this. So if you look at the guideline, the guideline is recommending that primary care, the intervention is to screen or to assess whether a woman might be at risk and then offer her genetic counseling. It's not going right and saying, okay, if you're at risk, you should get a BRCA test. The genetic counseling is very important. So I don't have anything against like a 23andMe if it's being paired with genetic counseling. But some of the counseling as an example is, well, what would you do if you have a positive test? So the way BRCA testing works in reducing deaths from breast cancer is a woman who is BRCA positive might do more intensive screening like MRIs and a woman who, or might do a preventive bilateral mastectomy. So if a woman said that she wouldn't do either of those, then identifying this is not likely to benefit her. And the other thing to think about in that genetic counseling is, well, how worried would a woman be if she were positive? So if someone were to have a lot of anxiety and be worried about this, that could cause a lot of harm without benefit if she were not to do anything about it. Now, there may also be in genetic counseling reasons to do it to find out information for family members. So a woman may want to do this to try and give information to her children as an example. So that's what the genetic counseling is getting at and thinking about, is this going to be a net harm or a net benefit? All right, let's move to lung cancer screening now. This was updated in March 2021. I think your board questions are going to be up to date with this recommendation. The U.S. Preventive Services Task Force recommends that adults age 50 to 80 years who have a 20-pack-year history of smoking and currently smoke or quit within the past 15 years should be screened for lung cancer with a low-dose CT scan. This is one of these recommendations that there's a lot of specific variables here. So this is an easy multiple question, a multiple-choice question, where they give you someone who's, you know, they give you different age ranges, different pack years, different time period for quitting, or maybe they tell you to do a full CT rather than low-dose. So take a moment and memorize age 50 to 80, 20-pack-year, quit within past 15 years. And you want to do this on folks who are healthy enough to undergo curative surgery to remove the lung cancer if it's found on detection. So that's one of your criteria to also think about, you know, make sure they're healthy enough to be able to undergo treatment if they find lung cancer. So there are five trials on low-dose CT for lung cancer. The NLST and the Nelson are the main ones. I haven't said this throughout the talks yet, but I don't think you're going to need to know the specific trials. So I'm not sure I would memorize those for the purposes of your board review. I mainly want to share them with you just so you understand the evidence behind the recommendations. Just, at least for me, that makes it easier to remember these things. There have been three other studies, Dante, DLCST, and Mild. But each of those didn't have enough people in them to recommend or really to see. They weren't powered enough to demonstrate outcomes. NLST was the first trial, 53,000 people, done in the U.S. age 55 to 74. They enrolled people with at least a 30-pack-year history of smoking. And the average person got three annual CTs. So I will say the first lung cancer screening recommendation was in 2014. And they had an age group of 55 to 74 and a pack year of 30 because of the NLST. So if for some reason you're reading the board review question and they say according to the 2014 U.S. Preventive Services Task Force, it'd be 30-pack years and 55 to 74. But if they don't specify it, go with the current recommendation of 50, go with the current recommendation of 50 to 80 and a 20-pack-year history. The Nelson trial enrolled 13,000 people or 13,000 men, 2,500 women, age 50 to 74. They had a lower average pack year than in the NLST. It was 38-pack years. So they wanted people to have these criteria of, you know, more than 15 cigarettes for more than 25 years. Once again, I don't think you need to memorize this. But the Nelson trial came out more like 2018 or so. And this is what spurred the U.S. Preventive Services Task Force to lower the age in the pack years plus some modeling showing that this would result if we lowered the age in the pack years, we would save more black male smokers' lives and there'd be greater health equity. So that was part of the motivation for lowering the age and the pack year. The lung cancer mortality NLST and Nelson both showed pretty substantial reductions in lung cancer mortality. As I mentioned, Dante DL-CST mild really didn't have enough power or follow-up. And mild was a poor quality study. I think what I want you to know, and this is an important thing for your boards, but also just for clinical practice and everything else, is that lung cancer is important. So lung cancer causes more deaths than breast, colon, and prostate cancer combined. So it's the number one cancer killer of men and women in America. It's a big deal. We need to address it. And if you look at those, the Nelson and the, well, actually the Nelson trial, there were a total of 3,000 deaths. A third of them were from lung cancer. And three annual screens prevented 187 to 249 of those. And you compare that to the European trial for prostate cancer screening, the ERSPIC trial, where there were 20,000 deaths, but only 522 were from prostate cancer. So it's just a much smaller number of people. Now, that's not surprising since the NLST trial had people with a 50-pack year history of smoking. So these type of individuals are going to have high rates of dying from lung cancer. Something else to know is that false positives are common. So this is where there is a little kind of controversy around the task force recommendation. I mean, clearly this saves lives. It not only reduces lung cancer mortality, it reduces all-cause mortality just because so many people died from lung cancer. But there is a tradeoff of false positives here. So if 1,000 people are screened, 250 are going to have a positive screen. There's a 96% false positive rate, at least in the NLST trial. In the Nelson, the false positive rate came down, but it was still pretty high. And there are complications and even deaths after diagnostic procedures and treatments which may be unnecessary. So that is a tradeoff. But if you add all of this up, the benefits really do strongly outweigh the harms. The catch is to make sure you're doing it for the right patients. So that's why I said at the beginning, making sure that people are healthy enough to undergo potentially a biopsy or a lung resection. The other thing is since the NLST trial, we have these new criteria called the lung RADS criteria. And this is a better way of differentiating which findings are significant and which ones are not significant on CT. So we can do a better job about deciding who needs a biopsy and who doesn't. Incidental findings are common. So if I were making a board question, I might ask this. Like what do you do if you do a lung screening CT and you find coronary calcium or you find COPD or you find non-significant lung findings? And the answer is nothing. So, you know, the task force gave an I statement around coronary calcium. We talked about that earlier. It's a D to screen for COPD for cardiovascular disease and whatnot. Go back to your primary prevention and the other recommended preventive services. And of course, if people have a 20, 30, 50 pack year history of smoking, you're going to see coronary calcium. So I'll say as a clinician, when I order this test, I usually warn people that we are going to see abnormalities. And this is something to be expected and that we'll sort out together what to do with it. But for the most part, we don't need to do anything outside of looking for the lung cancer findings that is the reason we're screening. We did look at, the task force looked at evidence to say, okay, well if you have lung cancer screening, does that mean people are going to feel more confident that oh, I don't have to quit smoking because we can find cancer early and reduce deaths? And in the two randomized control trials, there was no difference in smoking cessation rates or intensity or relapse between the groups. So, and one of the two trials suggested that people who had an abnormal scan might be more likely to quit. And two out of three cohort studies suggested that there was some decreasing smoking with people at an abnormal CT scan. So, you know, that's not a drawback. And paired with screening for lung cancer, we should always be counseling people to quit smoking if they're still an active smoker. Thinking about skin cancer screening. So, the task force has, I think this has actually been updated just this past year as well. But it's been an eye for many, many, many years now. It's still an eye. So, there's insufficient evidence to recommend four against total body skin exam for early detection of skin cancer. So, you know, among primary care clinicians, there's a variable rate of referral and biopsy. We do detect melanoma. There's some studies of healthy volunteers who show up. And you can find about one to four cases per 1,000 people with exams. Where we're uncertain is, does this change mortality? Would these melanomas have been found otherwise? Are there differential outcomes? And obviously, for people who are at higher risk, people greater than ages 65, people with multiple moles, atypical moles, there may be some reasons to examine their skin. And certainly, if people are noticing size, changes in size, shape, or color of skin lesions, well, those need to be evaluated. But in terms of screening, if you're asked, should clinicians routinely screen? The answer is there is insufficient evidence to recommend for or against this. Now, in terms of counseling high-risk populations, the task force did give a B recommendation in 2018 to counsel people age 10 to 24 with fair skin to minimize exposure to UV radiation. So, this includes like wearing hats, UV-protective clothes. It does include sunscreen, although, you know, there are some limitations with sunscreen. And some of the newer formulations might, or some of the older formulations may not be good for the environment. So, there's some drawbacks with sunscreen. But there is data that counseling people who are at risk does change their behavior in a way that the task force believes will change the development of future skin cancers. And then there's a C statement, selectively counsel, actually, this should say, selectively counsel people over the age of 24 with fair skin to minimize exposure to UV radiation. I'm sorry, this should not say the same thing. So, I apologize for that. Skin cancer prevention concepts, this is the list of people who are at higher risk. And as the prevention is really protective clothing and avoiding midday exposure and possibly sunscreen. Here's a list of preventive services that are not universally recommended. Bladder cancer screening is an eye, doing things like a urinalysis. Cancer is usually localized. It usually presents with symptoms like blood and urine. Pancreatic cancer actually has a D. You would find this through blood tests like a CA-19-9 or even imaging. The problem with pancreatic cancer is it occurs early, it rapidly spreads, and so our treatments aren't very good. So, screening probably hurts more people. We find a lot of those indolent cyst abnormalities that might not be significant. Oral cancer screening is an eye, so we're not really clear on the sensitivity and specificity of the exam. It is under review again and will be updated. Ovarian cancer is a D, done in 2018. This is both ultrasound, CA-125, and pelvic exam for ovarian cancer also. And there's no evidence that earlier detection is effective, and there is evidence of false positives, incidental findings, other things, over-diagnosis, over-treatment. Testicular cancer screening is a D, mainly because treatment is so responsive. It doesn't matter even if it's relatively spread. The treatments are pretty equally effective. And thyroid cancer is a D. This is being updated, but I don't see this changing in the future. And this would be an exam or an ultrasound. There's some interesting data from South Korea. So, for whatever reason, in South Korea, there's a high, it's very common in practice to get ultrasounds on people. So, over the past 20, 30 years, we've seen this tremendous uptake in people having body and specifically thyroid ultrasounds. And with that has been a 1,000-fold increase in the diagnosis of thyroid cancers and zero change in mortality. And that gives the task force pretty strong confidence that, you know, finding this cancer early does not change an outcome. Just to have that many more cancers found early and not changing an outcome is just, it's pretty impactful. So, the messages here are, you know, do the healthy behaviors to try and prevent cancers. Don't smoke, eat right, live in alcohol, get exercise. All those types of things will reduce the incidence of all of these cancers. There's a future topic in progress. Task force is looking at Lynch syndrome-related cancer in adults. So, nothing you need to know for the boards. I say this just to be aware of. Another future topic is anal cancer that is under review. Once again, nothing for the boards. Just I want you to know it for the future. Let's transition to mental health. This is an extremely important topic and, you know, we often think of prevention. We get focused on cardiovascular and cancer. More and more mental health we're realizing may be so much more important. We'll start with alcohol. But, you know, just in general, the pandemic made anxiety, depression, alcohol use, unhealthy behaviors, all of these things got worse. So, they're definitely up. And they haven't gotten a whole lot better as we've moved forward. This is kind of the fallout of the pandemic. So, if I were making board review questions, which I don't get to do, I would talk about mental health. I'd ask a decent number of questions about this because I think it's such an important topic. So, starting with alcohol, the task force in 2018 and prior to that recommended that clinicians screen and counsel all adults over the age of 18, including pregnant persons, about risky drinking. And when you look at the evidence for adolescents 12 to 17, there's insufficient evidence to recommend for or against. There is a decent amount of binge drinking and such in 12 to 17-year-olds, but the interventions just aren't that strong. I think it's reasonable to know these definitions. You know, if you think about alcohol, unhealthy alcohol use, there's this spectrum, right? So, risky use is men drinking more than four per day or 14 per week and women more than three per day or more seven per week. And going with that risky use or unhealthy alcohol use, just one caveat is men over 65, the recommendation is actually to have seven per week, not 14 per week. So, the 14 per week is applying for men under 65. Abuse is sort of that next phase, which is where you start to have consequences from the alcohol and problems. So, you might be having troubles at home or work or school or with relationships. You engage in physically hazardous activities, things like drinking and driving. Or if you start to have some, like, health effects from alcohol and you still continue to drink, well, that's an example of abuse. Getting legal and social problems are another example. And then that next phase is the alcohol dependence. This is where you have physical cravings, withdrawal, frequent consumption. You build a tolerance. And so, that's that next phase. So, the screening instruments are the Audit C or the Single Item Binge Question, which is often called the SASQ. So, this is the Audit C. It has categorical responses for how often do you have a drink containing alcohol? How many standard drinks containing alcohol do you typically have? And then how often do you have six or more drinks? Now, you'll notice, just to put a pin here, if you go back, we said unhealthy or risky use is four per day for men or three per day for women. That's a level that causes intoxication. That's how that's defined. The Audit C says six. It's strange that it does that, but this is what they put in the validated instrument. And this is how the Audit C considers binge drinking. The SASQ, which I don't have a slide for, the Single Item Binge Question, asks women how often do you have more than three per day? Or men, how often do you have more than four per day? So, the SASQ uses the unhealthy alcohol or the risky use or the amount it takes to become intoxicated. So, looking at the evidence here, the SASQ and Audit C have good sensitivity and specificity for detecting unhealthy alcohol use. I'll just share with you, we're completing a big trial through the Agency for Healthcare Research and Quality, part of their Evidence Now initiative. And we identified that clinicians infrequently use the Audit C or SASQ. But 70% of the time, they document something about alcohol during wellness visits. But only like 15% of the time do they use the Audit C and like less than 1% do they use the SASQ. And clinicians only detect 9% of patients with unhealthy alcohol use. And when we asked those same patients the Audit C in a survey, fully 24% scored in an unhealthy alcohol use range. So, it just gives you an idea of sort of the power of using these validated instruments. It's my little plea here for practice and for public health to make sure we're using the validated instruments as opposed to just saying, do you drink? Because you're going to miss a lot of people without using the instruments. Thinking about the counseling interventions, the task force identified 65 trials, more than 34,000 patients. And these interventions ranged from, you know, single session, multi-sessions. There was one intervention that the average time was two minutes. But overall, across the studies, it was about 30 minutes. There's web-based, personalized normative feedback, motivational interviewing, referral to cognitive behavioral therapy, personalized health feedback, stepped care. About half the time, primary care clinicians delivered the intervention. And these brief behavioral counseling interventions showed reductions in 6 and 12 months odds of exceeding weekly recommended drinking limits and binge drinking. So, you know, if you put this into context, we're going to talk more about other health behaviors. Smoking cessation counseling, on average, takes 2 to 10 minutes for clinicians. We're really good at that. Getting people to lose weight, I'm going to show you, takes about 26 hours of face-to-face contact over 6 months. This is 2 minutes to 30 minutes on average. It's very deliverable in primary care. And primary care needs to get better at doing this because this is a health behavior that we can help people to change and improve health outcomes. All right. Now, thinking about depression and suicide screening of adults. So, this was June of 2023. The depression part of this is not really different prior to this. So, I put in the most recent recommendation here. The suicide screening is the newest addition. It wasn't in the prior recommendation. I don't think a question is going to get at that level of nuance for you on your boards. So, just I would memorize this. But the task force gives a B for all adults, including pregnant or postpartum, above the 65 and older, to screen for depression. And gives an I for adults, including pregnant and postpartum, to screen for suicide risk. So, that's a newer one. And there are also recommendations for screening younger adults as well. So, this is really everyone. And then I'm going to show you a recommendation on screening adolescents for depression. So, when you're looking at your board questions and trying to answer this, the idea would be that depression screening is something that should be done for all adolescents and adults. So, depression is a leading cause of disability in the U.S. The cost and burden of depression in individuals can be pretty significant. It affects quality of life and productivity and relationships. And it also has a big cost and burden to society, including loss of life and reduced productivity. The depression screening question for adults is the PHQ-2. It's an effective screen. And it's, you know, over the past weeks, have you felt down, depressed, or hopeless? And over the past two weeks, have you felt little interest or pleasure in doing things? And then clinicians are supposed to follow up this with formal DSM-IV diagnostic criteria to evaluate and really more make the diagnosis of depression. So, the PHQ is the screen. It doesn't make the diagnosis, but identifies people who need a more detailed history and physical and think about applying DSM-IV diagnostic criteria. The treatment in adults is very effective. So this includes antidepressant medicines, includes psychotherapy approaches like cognitive behavioral therapy and brief psychological counseling. These can be done alone, it can be done in combination. I think the psychotherapy approaches in practice are really underutilized. So I would put a plug in that we need to do a better job of doing psychotherapy. There is definitely shortage of therapists and folks in care teams who can do CBT or other types of psychosocial counseling. There is a call out for something separate for pregnant persons, which is, you know, given the harms of the medicines, clinicians are encouraged to consider the psychotherapy approaches first, or more primary for managing depression in pregnant or breastfeeding women. Medicines can be used. So there are ones that have been designated as safe, but if I were answering a board question, you know, if they ask you what is the first line of treatment for pregnant persons, it would be psychotherapy. So kind of look for that nuance of a question. Thinking a little bit about suicide prevention. Suicide is up. It is a major health problem, both for adolescents and for adults. When you look at the evidence, there are screeners for suicide and they're okay. But when the task force looked at all of the evidence, they did not necessarily see that screening for suicide improved health outcomes and most specifically reduced, it didn't, from what they could see, it didn't reduce completed suicides or suicide attempts. This slide shows all of the things that the task force called out for needing more evidence. So we need, you know, better understanding the accuracy of single screeners. We need to know whether more individuals with screen detected suicidal ideation could be helped before they act. We need treatment studies in populations. We need to understand the potential harms of suicide risk interventions. And then certain populations of people who are at greater risk, you know, how did the guidelines change for them? I think if you're asking, answering a board review question, the good thing and the good thing for clinical practice here too, is screening and treating for depression can help to prevent suicide. So partly improving mental health is our pathway for reducing suicide. The, you know, how to directly prevent suicide is a little bit different. If you're answering board questions, I'd say, you know, we're not sure right now there's insufficient evidence. Although I'd read the question closely because if they talk about veterans or people who are particularly high risk, depending on the wording of it, it might be appropriate to say that you would at least inquire about it. Another recommendation related to depression. So we just said we wanna screen and treat all adults. And I'm gonna get to kids in a second, but here's the guideline recommendation about preventing perinatal depression. So this is for people who are pregnant or postpartum. And the task force gives a B recommendation to refer pregnant or postpartum persons who are at increased risk of perinatal depression to counseling interventions. So this is not screening for a depression. This is someone who is pregnant and trying to be proactive in preventing this. Perinatal depression is very common. It can develop one year after childbirth. It affects one in seven women, mothers annually. And it's one of the most common complications of the pregnancy postpartum period. And this has significant impacts on both the mother and on the child. So it's a big deal. Looking at the evidence, there were 17 different RCTs and showed a 29% reduction in the likelihood of becoming depressed. And the main benefits were cognitive behavioral therapy and interpersonal therapy. And the number needed to treat was just 13 pregnant people. The harms were, the reported harms were really pretty low. And some of the trials did include antidepressants. And they seemed to be relatively safe in terms of pregnancy. They had some light quality of life effects like constipation and drowsiness, but seemed to be pretty effective. Cognitive behavioral therapy, if you hear this, this is about addressing negative thoughts, increasing positive activities and actions. This is the idea about recognizing what you can control and not control, act on what you can control and learn to accept what you can't. Interpersonal therapy is talking a lot more about individuals' relationships with other people to improve communication and address problems that contribute to depression. So thinking about a primary care clinician, if you identify a person who might be at risk, you would be going in, and at least I tend to try and start with thinking, okay, is this person gonna benefit more from CBT or interpersonal therapy? And this is where I try to ask more about kind of their life and some of their factors that might be influencing and affecting their mood. So the big challenge with this recommendation is, okay, well, who do we refer? Like, are we talking about sending every single pregnant person? That might not be a bad thing. I'm not sure the country has the resources for it, but in the different trials, they were really referring people who had these risks. And these were the types of risks that people had who were in the trials. They had a history of depression. They had some depressive symptoms. They had lower income. Some studies just said any adolescent, because adolescence is a risk. Some studies said any single parent, recent or past intimate partner violence, or other mental health-related factors. So these would be the types of things that you would think about. And then the question is, well, when do you refer people? Most of the studies did the interventions in the second trimester of pregnancy. But the short answer, and per the task force recommendation, is it could be any time. I think at any point in time that a clinician identifies a person who's pregnant or postpartum, and they have concerns, this should be offered to them. But it's most often done in the second trimester in the different trials. All right, I promised we would move to adolescents and children. So here are the recommendations for adolescents and children. And these are actually pretty similar to the prior recommendation. So I think that I put in the October 2022, because I think this is what I would learn for your boards. And the task force is recommending adolescents aged 12 to 18 should be screened for major depression disorder. And children 11 years and younger, there's insufficient evidence to recommend for or against it. And suicide was the thing that was added in 2022. The prior ones didn't include that one either. But it was insufficient evidence to screen adolescents or children for suicide. So really, I've given you this picture that people 12 and older should be screened for depression. We need more evidence for suicide. That's what you should know for the boards. So depression in adolescents and children causes a lot of functional impairments. It affects school and work and learning. It affects building social relationships and interactions with family. And it negatively affects your developmental trajectory. So doing interventions on children early in their life can have a major beneficial impact over kind of a life course trajectory. And that's super important to know. Major depression in children and adolescents is strongly associated with depression in adulthood too. And suicide is the second leading cause of death among youth ages 10 to 19 years. Depression screening is most commonly done in kids with the PHQ-9. So this is like the PHQ-2, but it includes seven additional questions. And I just need to say, the PHQ-9 has a question about suicidality on it. And I see many clinicians and health systems very scared about asking that question because they're afraid if they get an answer and they don't act on it, that they're gonna be liable or they're gonna be problems. And I just need to put a plug in looking both at the evidence on suicidality for adults and for adolescents. There is no evidence that asking about suicide increases a person's likelihood of attempting or completing suicide. So asking this question is not going to cause harm based on what the task force has found when they were doing their suicidality recommendations. And I would even put out there that if someone is suicidal, it really doesn't matter if you ask or not ask, they're at risk for this. It is what it is. And I just think as clinicians, we have an obligation to ask people about it, even with the risk that by the time if it's automated through your EMR and you don't see it for a day or two, everyone's terrified of that. But I think it's still much safer and better for people's health to do that than to not do that. So, okay, stepping back, there are other screening instruments that you can do as well, both for adults and for kids, there's really no evidence about what's the right interval. For adults, the task force said, every one to two years is probably reasonable. It's not in the top line, but it's in the practice considerations. And for adolescents, the task force took much more the stance of opportunistic screening might be much more appropriate because adolescents really don't come in. So if you kind of wait for that annual wellness exam, you're going to miss the kids that we should be asking about this. Thinking about treatment, there were 13 RCTs. A lot of them included cognitive behavioral therapy, interpersonal therapy, they have the most evidence. And then they had these two medicines that are approved. So fluoxetine is approved for kids eight and older and is set citalopram. I can't say that, I apologize, is approved for kids 12 and older. They do have black box warnings about increasing suicidality and unusual behavior. So usually once a kid or adult has started on these medicines, we should be following up with them and checking to see how they're doing, two weeks or so, or two days if you're worried after starting these medicines. The suicide treatment, there were 16 RCTs. Four trials showed reduced suicidal ideation measured by this Beck hopelessness scales. Most of the others were underpowered and it was really unclear what the clinical significance of this, does this Beck hopelessness scale and slightly lower suicidal ideation scores on this instrument translate to fewer suicide attempts or completed suicides? We just don't know that. And that's an area that the task force is calling out for more evidence. Let's transition now to anxiety for adolescents and children. This was done in October of 2022. I think this is reasonable and fair game for boards. And if they had a question, prior anxiety was not a task force recommendation. I can't imagine that they would ask you something related to prior to October. And the answer being the task force doesn't have a recommendation on that. That doesn't seem like a good question. So I would learn this. The task force is recommending children and adolescents aged eight to 18 be screened for anxiety. It's a B recommendation. It's an I for children, seven and younger. So this was big news. And there's lots of discussion about anxiety in kids. You know, in 2018, 7% of adolescents had generalized anxiety and we see that anxiety has been increasing. You know, it began to deteriorate around 2009. A lot of people link this to social media. I put dates of social media here. We don't know that for a fact. There may be some evidence around this though. I think it depends on the person and how they're using social media. Thinking about screening, there's a number of instruments in the literature. The two main ones that are used in practice is the SCARED and the Social Phobia Inventory. So those are probably the ones that I would do. But the task force specifically said there's a lot of instruments that are done in practice. So I don't think you'd be asked a question that says the SCARED or Social Phobia Inventory is the right one in teasing out one screening instrument versus another screening instrument. You might be asked a question where, you know, should you just ask generally, are you anxious? And the answer to that is no, you should use a screening instrument. So if there's a choice on a multiple choice and they give you a screening instrument versus just asking kids if they're anxious, use the screening instrument. And treatment can include psychotherapy, it can include pharmacotherapy or a combination of both or collaborative care. So this was collaborative care is really when kind of primary care and the medication management is managed more in a team effort with the psychotherapy team. That's probably the most effective for mental health across the age spectrum and depression or anxiety. CBT is most commonly used for kids in the trials and duloxetine is the one medicine approved for kids seven and older for anxiety. So duloxetine is the one for anxiety and then fluoxetine is talopram for depression. I don't know if your boards will get into that but those are the differences there. A brand new one was a screening for anxiety in adults came out at the same time. This is for adults 64 years or younger, including pregnant and postpartum persons and recommends that the screening for anxiety now in adults. This may or may not be too recent and too big of a change to include on your boards. It's worth knowing that this guideline occurs if they ask a question, I think the answer is yes, you should screen for adults for anxiety. If it's not included on the boards, they're just not gonna ask the question. Wanna transition now and talk about social needs. So there are several specific task force recommendations around social needs, intimate partner violence, elder abuse and child maltreatment. And there's more coming out about approaches to social needs like the task force's approach on structural racism and the task force's approach to sex and gender. I think these would all be fair game for board questions. Certainly structural racism, social and structural factors that kind of affect our needs are big issues as well. So I'd be careful about how you read these questions and so let's talk through this. So intimate partner violence and the B recommendation is really the only task force recommendation on specifically screening for a social need. There's a couple that sort of vary on this and we'll come to that at the end, but the task force gives a B for screening women of reproductive age for intimate partner violence. And there's an I for screening older vulnerable adults for elder abuse. So this is obviously a big issue, but there's not a lot of evidence that that screening changes outcomes. So intimate partner violence includes a broad range of categories, physical violence, sexual violence, psychological aggression, stalking, all of these things. And it involves a person with whom one's had a close personal relationship. It's very common. So more than a third of women and nearly a third of men experience intimate partner violence during their lifetime. Severe physical violence is less common, but it's still 21% of women and 15% of men. And then if you look at older adults, abuse and neglect, it's 10% of older adults. So these are big problems and ones that we need to address on a societal level. Here's sort of the prevalence of the different types of intimate partner violence experienced by men and by women. I don't know if you're gonna have a lot of questions about this. I think if you're asked a question, women are more likely to experience the physical violence and such than men. I think that's a fair question, but I'm not sure they're gonna get into parsing these percentages out here, but I wanted to show you so you could see sort of the coercive control and expressive aggression. Some of this psychological violence is more common than physical violence, and it's very important in terms of its effect on people. There's a number of detection instruments, the HARC, the HITS, the eHITS, the PVS, and the WAST. All of these are reasonable things to use. I think same thing as anxiety. I don't think you're gonna get questions saying, do this one and not this instrument. Like I wouldn't memorize here are the five instruments to use these different acronyms. I don't think they're gonna throw in and make up another instrument that's not a detection instrument. But you might be asked, should you use a screening instrument or just ask women if they've experienced intimate partner violence? And the answer is you use a screening instrument. When you think about the trials, there are five big trials on treating women who would be screen detected in reproductive age. And three of them were statistically significant, two were not. One followed birth outcomes. It showed a decreased low birth weight. Another showed reduced, two showed reduced depression. And one showed kind of mixed results on different aspects of quality of life. And then there were six trials in non-pregnant women. Five evaluated the frequency of intimate partner violence and two showed reductions, three did not. And three trials followed depression, two showed a reduction, two trials followed quality of life and there were no differences. You put all these together and this is where the task force was very mindful in saying women of reproductive age. So the evidence is a little bit stronger in pregnant and postpartum women. That's the most common time period to experience intimate partner violence, but there is some evidence for non-pregnant women, but they do tend to be women of childbearing age. Thinking a little bit about other social and behavioral health, this is where I said that the B for intimate partner violence for women is really the only recommended one. There is, if you count STI counseling, behavioral counseling to prevent STI in sexually active adolescents, that's a B recommendation. If you count that as a social need in a behavior, then you could say that there are two of these. There's an I for screening for cognitive impairment for older adults. It is mandated in the annual wellness visit. So if you're asked, should you routinely do this per U.S. Preventive Services Task Force? I would say no. If you're asked, is it required as part of the CMS covered annual wellness visit? I would say yes. So look for that question. And there's an I to screen children with no signs or symptoms to prevent child maltreatment. So just like the older abuse, same thing with kids. There's no evidence. The evidence is insufficient at the moment for screening children. And then screening adults and pregnant persons for illicit drug use is now an I, or actually, let me step back. I put a caveat here. So the 2020 draft, which then became a recommendation like 2021, 2022, moved this to a B recommendation. So it is a B recommendation now. In 2008, it was an I. I'm not 100% sure where your boards would go with this. I think this would be something where they're either gonna not ask it about screening all adults and pregnant persons for illicit drug use, or if they do ask it, it would be a B. It's kind of in that window where it could be, but may not be included on your board. So this is actually another B. So these are our three Bs. I apologize for that. And this was largely driven by the increased death around opioids and the evidence on treatment for opioid use disorder with medications demonstrating effectiveness. So the majority of driving the change of screening adults and pregnant person for illicit drug use was around opioids as opposed to other drugs like marijuana or injectables or other types of medicines like that or drugs like that. The task force does not have recommendations on most social risks. So I was trying to put all these into context in this social needs bucket. We know transportation, food, dental, safety learning, social connections, loneliness, education, financial situation, work, housing, all of these things affect health. And I would probably put questions about loneliness and, you know, does loneliness result in worse health and health outcomes? And the answer to that is yes. There's no recommendation from the task force on these and the evidence is emerging. You know, many health systems right now are telling clinicians that they should screen for social risks and they should ask about these things. A lot of electronic health records have this built into them. We know that social needs and social risks have a much bigger impact on health than any of the clinical preventive services we can do and that's where a lot of the appeal is about asking for this, the social risks. We don't have as much evidence that healthcare and healthcare systems change this. We know that countries that invest more in social needs than healthcare, like every other developed country than the U.S., have better outcomes. So I would read any questions about these types of social risks very closely. If they're asking you are they big, do they impact health, the answer is yes. If they ask you does the U.S. Preventive Service Task Force recommend screening for them, I would say that the answer is no outside of the ones that I've showed you already. If they ask you do we have, you know, conclusive evidence that the healthcare system can address these things, I'd be a little hesitant on that. I'd have to read through the questions closely. On the right-hand side, though, I will share that the task force did an evaluation on how it's addressed social needs, you know, recognizing that many of the social risks we don't have explicit recommendations on, but we looked at how many recommendations are social risks incorporated into the recommendation. And the answer is a surprisingly large number of them. So among 85 recommendations that we reviewed, 14 were focused on preventive services that are more health-related social risks, but 57 out of 85 had some element of social risk incorporated into the recommendation statement. You know, this might be about how, you know, which populations are at greater risk or have worse outcomes or even where there might be some nuances in ways that treatment needs to be tailored or individualized for certain groups. That comes out in there. So if you're asked a question, do the task force recommendations incorporate social risks, you know, do many recommendations, I would say yes. I don't think they're going to ask you that, though. Racism is another thing that the task force was trying to address back in 2021. And you've heard me say on a number of recommendations, like lung cancer screening, part of the evidence to lower the PAC years and lower the age was to create greater equity between black male smokers and other smokers. And it was a factor in the colon cancer screening recommendation. And now it was a factor in the most recent mammogram recommendations. The task force has committed to including equity in all of its recommendations. It's committed to considering race as a social construct, not a biologic construct. There is no biologic reason that black people have worse colorectal, lung, or breast cancer outcomes. It has to do with systemic and structural racism that is contributing to these factors. And the task force has an approach that they're trying to incorporate and assess and evaluate the impact of racism as causes for inequities and trying to look with each recommendation about interventions to address systemic racism and improve these outcomes. So you may get some questions about this and how it impacts health and outcomes. And use your good test-taking skills kind of building on these concepts that I mentioned here. Sex and gender has often been an issue in task force recommendations. And you've heard me in these presentations, you'll see a lot of the guidelines, they'll recommend things like the task force is recommending cervical cancer screening for women of these ages. So women is a gender term as opposed to female, which is a sex term. The task force has really tried to make guidelines and recommendations much more clear. And also to try and be much more inclusive in the recommendations. So what you'll notice is in the practice considerations of every recommendation, under the population under consideration, there are statements that say, for example, with cervical cancer screening, we say by women, when we refer to women, we are referring to persons with a cervix. And there's some caveats in there. And whenever possible, the task force is looking at every subgroup in every different community that might be impacted differently and have different evidence or different outcomes. So just like the task force might look at race or income or education as a risk in a differential for outcome, the task force is trying to look at sex and gender and look to see if there are different outcomes or recommendations for transgender or intersex people. There is a recurring problem that there's not a lot of evidence. So going back to the methods that I talked about at the very beginning of this presentation, getting to certainty is really hard for transgender and intersex people. So more often, I would just say that we're going to need to rely on expert opinions as opposed to, for example, a task force recommendation, which is supposed to be just kind of evidence, completely evidence grounded. We're going to need good evidence-informed expert opinions. And we are going to need more evidence for transgender and intersex people to be able to better address sex and gender. But look in the practice considerations and the population under consideration to really understand who the task force is talking about when they start talking about their evidence. I'll just close, too, with one of the other challenges that the task force has run into is that when looking at the original evidence, it's almost impossible to tell what people mean in terms of the terms they use. So, you know, while the task force might say our recommendation statement applies to all asymptomatic individuals with a cervix, a lot of the studies on cervical cancer screening have a column where they say, you know, men and women. And, you know, the task force assumed when they said women, they were referring to all asymptomatic individuals with a cervix. But we don't know that for a fact. Maybe it was a gender term, although many of these studies, particularly ones back in the 90s and 2000s, didn't have the right approach to this. So it's just difficult to interpret the evidence when making these recommendations. I want to put placeholders. This is not for your boards. But looking to the future topic, the task force is taking up food insecurity. So they thought by looking across the evidence of screening for different social needs, that food insecurity might have the greatest likelihood of being able to get to moderate certainty and make a recommendation. So that's why they picked that topic. And they are thinking about these other social needs topics as well. I'm going to stop here for this part. All right. Now let's transition to metabolic, nutritional, and endocrine conditions. So this spans a wide range of topics, nutrition activity, obesity, diabetes, hormones, thyroid, vitamins, and kidney disease. So starting here first with nutrition. So the task force gives a B recommendation for adults with cardiovascular disease risk factors to offer or for adults to behavioral counseling to promote healthy diet and physical activity. So the risk factors include hypertension, dyslipidemia, impaired fasting glucose, or metabolic syndrome. The types of interventions that demonstrated a beneficial impact involved 5 to 16 contacts over a 9 to 12 month time period. So these are intensive interventions to try and help people change their health behaviors. A lot of the studies were part of the diabetes prevention program, and I'll talk in a second about what's involved with those to give you kind of a clue about the type of interventions it takes to get people to change diet and exercise. But from a board standpoint, know that this is a recommended preventive service. It's a B for everyone with cardiovascular risk factors. The task force also gives a C to adults without cardiovascular risk factors. So remember, C is selectively counsel patients. You know, the primary harm of this is the opportunity cost. So do you do this versus other things? I think I mentioned when talking about shared decision making at the beginning that, you know, if a patient has a lot of other questions or concerns or issues, I might not address this, even though I think it's important. Or if they have other things such as quitting smoking or unhealthy alcohol use that I can more effectively deal with, I might deal with that. But this is something to think about depending on a person's risk. And there's more to risk than just the cardiovascular risk factors I showed to you prior on the prior slide. There's also things like readiness to change, social support, community resources, and other health issues that a person has. The diet and exercise counseling for adults without cardiovascular risk factors are probably less intense. But they're probably not like the two minutes to 30 minutes that I shared with you with unhealthy alcohol use. But they're probably a little less intense than diabetes prevention program type interventions. I will say, you know, I'm a family physician. I've been at my practice for 30 years. And my patients have heard me say these things over and over and over again to them. So I also think about intensity over a longitudinal relationship. And I have patients that have come in after 10 years and say, Doc, I'm finally listening to you. And I've started eating more vegetables. So even though I do a briefer intervention, you know, that might have some change over time and impact as people's readiness to change changes. So you should all know about the different healthy diet, you know, what should you eat, not eat, what should you do for exercise. The 2000 dietary guidelines, and these are updated every five years, introduced this nice ABC framework, you know, aiming for fitness, building a healthy base, choosing wisely. I think these are good things to know and think about. So the aiming for fitness is balancing what you eat with what you burn off. The building the healthy base is eating a good healthy variety. The choosing wisely is avoiding the unhealthy things, so fat, alcohol, salt, sugars. And it's avoiding because everyone does eat some of the things that they shouldn't eat. The more recent guidelines talk about concepts like following healthy eating patterns across the lifespan, focusing on variety, nutrient density. So we have a lot of high-calorie foods in the US, which is a problem in the amount you eat. Once again, limiting calories from the unhealthy sugars, saturated fats, sodium. Shifting healthier food and beverage choices. I found in some of our studies that we can have a lot of success with people, you know, giving up and quitting like daily soda intake or biweekly fast food intake. So having specific things can help people as you're counseling them. But, you know, these are all the general guidelines of what we want people to do to be healthy. The 2015-2020 guidelines talk about supporting healthy eating patterns for all. So they introduce the concepts about equity here in the dietary guidelines. And they talk about considering the impact of diet on environment. And I'll never forget a master's in public health class that I had when I got my MPH. And I had an environmental health class. And I'm not going to remember the exact numbers, but the acreage it takes to feed a family for a year on vegetables is, you know, one level, like an acre or less. And to feed that family on chickens is, you know, like 100 or 1,000-fold higher. And then on beef is like 10,000-fold higher. So, you know, the type of food that we eat has an impact on the environment because beef, compared to chicken, compared to fish, compared to vegetables, you know, these have higher burden and land demands to support and maintain. And then they have higher emissions of greenhouse gases and other things as well. So that's something we need to think more and more about as we're seeing all the climate changes. And the guidelines in 2015 to 2020 did do this, which was really pretty amazing. They talk about some concrete things. So less than 10% of your calories a day should be from added sugars. I try to get my patients to make this almost zero percent. But the guidelines talk about less than 10%. Consume less than 10% of calories from saturated fat. Consume less than 2,300 milligrams of sodium per day. And if you drink alcohol, drink it in moderation. So those unhealthy alcohol use numbers I told you before, these are reasonable numbers to know for board review questions. You might get asked something along these lines. Physical activity, if you get asked what does it do to help, pick all of the above. It does everything. It reduces premature mortality. It extends life. It reduces all kinds of chronic conditions, obesity, mental health, depression, anxiety. It promotes psychological well-being, cancers. So it's hard for me to imagine a question where they're going to have options that are not benefited by physical activity. This would be one of these all of the above choices. The physical activity that they talk about in the dietary guidelines in 2010, which really kind of have been perpetuated throughout, you know, they talk about 150 minutes a week of moderate activity for substantial health benefits. And if it's vigorous, you know, 75 minutes. And then for more extensive health benefits, you know, 30 minutes of moderate activity and 150 of vigorous. I think some of the concepts here is aside from overuse injuries and things like that, more activity is better. The other concepts I'd be thinking about is, you know, sedentary lifestyle is bad. So getting up and moving about throughout your day is very important. We've moved away from saying that people have to do all of their exercise all at once. If it's, you know, broken up throughout the day, that's fine. But some of these numbers, if you're asked, like how many minutes a week should people do moderate activity, I would answer 150, which basically comes down to 30 minutes most days per week, i.e. five days a week. So these are probably the concepts I'd be thinking about as you're looking at your board review questions. So thinking about weight loss to prevent obesity-related morbidity and mortality in adults. This was 2018, and the task force recommends that clinicians offer and refer adults with a BMI above 30 to intensive multi-component behavioral interventions. So this is not so much about screening for obesity anymore. It's much more about counseling people who are obese and trying to help them to change lifestyle patterns to address their obesity. And high-intensity counseling is aimed at skill development and motivation, support strategies. And these types of things do produce sustained weight loss, four to seven kilograms for a year. Obviously, all of us know that there are more medicine options that are emerging here. I mean, I think if you're asked questions like, you know, what should you do first? The answer is always counseling and lifestyle changes. I think as you're looking at board review questions as well, or board questions as well, if they give options with like medicines alone, I mean, even with the newer medicine options that result in pretty substantial weight loss, you know, these things don't work unless you're pairing it with lifestyle changes, or they work temporary. Even surgery, like weight loss surgery and gastric bypass, they have to be paired with lifestyle changes. So think about that as you're reading through and looking at these questions. There's no direct evidence for this on morbidity and mortality, but at least in these trials with the four to seven kilograms of weight loss, there were a lot of changes in intermediate outcomes, glucose tolerance and blood pressure and cholesterol. You start putting all that together with the sustained benefits of the weight loss, and that gave the task force confidence that there would be an improved health outcome for people. Similarly, for kids, kids is more about obesity screening. So it is about screening children and adolescents six years and older, and then offering them comprehensive intensive behavioral interventions. So that's in the top line, but the preventive service is written as screening, where the other preventive service for adults is about is a counseling recommendation. And these are the interventions that I told you are defined for adolescents as 25 hours of contact with the child and or family over a six-month time period. Interventions that impact the whole family tend to be more effective if you're asked questions along those lines. I think any intervention, as long as it has the right intensity and the right approach, can be effective. But if they get at, you know, interventions that just address children or interventions that address children and the family, children and the family is going to be better. Here's just a visual I want you to see. The line, this is the forest plot, and if these are the individual trials and how intensive the interventions were, and if the confidence interval line goes over that middle line there, it means it was statistically not significant. And there were 42 treatment trials, and they had treatment trials for kids that were lower intensity, the zero to five hours, but all of those crossed the line and are not statistically significant. So it really is the 52 or greater hours required to get to the significance. You start to see it at the 26. But the more time, more intensive, the more effective these interventions. You probably need to know these criteria. The definition of obesity is calculated by the BMI. Yes, that's only one measure, so waist circumference and, you know, percent fat and all these other things are also measures and another variable to consider. But BMI is really clinically kind of one of the main factors that drive things. And obesity is a BMI greater than 30, overweight is BMI 25 to 30. The number, I need to change it. So I think it's now something closer to 40% of adults are obese, and a third of Americans have a BMI that are 25 to 30, and only a third are below 25. And for adolescents, the obese BMI is greater than the 95th percentile comparing them to other adolescents, and overweight is greater than the 85th percentile. I don't think they're going to ask you statistics like what percent of adults are obese. I'm not sure I would be spending my time studying to remember those types of things. But I would know 30 and 25 to 30 and the 95th percentile and the 85th percentile. Those are all reasonable board questions. There sometimes are questions I've heard about like how many calories does a gram of food have? So, you know, protein's got four calories per gram, carbs four calories per gram, and fat is nine calories per gram. The gist of what you need to remember as you're answering these questions is that fat is more than twice as many calories per gram. So, this gets to that food density issue. So, if you take something like vegetables, which are primarily carb and some protein, plus there's a lot of non-digestible content in there, you know, a much lower calorie content of vegetables fills up your stomach compared to what it takes for fat to fill up your stomach. So, if you Google 400 grams of fat, you know, what does 400 grams of fat look like? And you do an image search, there's these three pictures of stomachs where there's this little sliver of the stomach full if it's fat. And it's like a third full if it's meat. And it's completely full if it's vegetables. In general, to gain or lose a pound is about 3,000, 3,500 calories, somewhere in there. And most people should eat about 1,500 to 2,000 calories per day to maintain their body weight. So this starts to give you a clue about, well, what does it take to lose a pound? So if your daily caloric intake is 2,000 calories because of your size and your gender, and you reduce what you eat by 10%, which is 200 calories, it takes you about 17 days, 15 to 17 days for 200 less calories per day to equal that 3,000 to 3,500 calories. So for most people, when they're trying to lose weight, losing one to two pounds a week is a reasonable goal for them to have. And reducing what you eat by 10%, most people feel that and notice that. And that's partly where losing weight gets to be so difficult. It really is about little changes over time and sustaining them. So a lot of people who give up a soda a day, that could be 150 to 200 calories a day that they're giving up. Or if you give up a beer or a glass of wine, once again, might be one to 200 calories a day that you've just changed. And over time, that starts to add up. And the opposite happens, which is why obesity is going up. Many people can add a soda a day to their diet, not really be aware of it, but a soda a day every day, if it's 200 calories in 15 days, you've put on a pound. So the task force also gives a B for screening adults 35 to 70 who are overweight or obese for prediabetes and diabetes. And then if you have prediabetes, offering effective preventive interventions. The data around this is primarily that finding people with prediabetes and enrolling them in a program like the Diabetes Prevention Trial will reduce the number of people diagnosed with diabetes. And those diabetes prevention trials have now shown for a decade, two decades even, that you have a sustained reduction in the diagnosis of diabetes. And that's what gave the task force confidence that we're improving the health outcome here by screening for diabetes. So the American Diabetes Association recommends screening all average risk adults age 45 and above and people with risks 20 and above. And they say, do a glucose or an A1C, a fasting glucose or an A1C. The task force is 35 to 70 people who are overweight and obese. So read the question. If they say, what is the American Diabetes Association, it's screen everyone 45 and above. If it's the U.S. Preventive Services Task Force, it's people 35 to 70 who are overweight and obese. 9% of the population has diabetes. Most are type two. Different factors that contribute to this are sedentary lifestyle, obesity, diet, genetics. It's the seventh leading cause of death. It's a big deal to find, and if we can reduce it. And the macrovascular complications are really the leading cause of death for diabetes. This is heart attacks and strokes. So the primary thing that kills people with diabetes is heart attacks and strokes. Now the microvascular complications we very much worry about, and diabetes is the leading cause of blindness and kidney failure and amputation. That's the nerve impact, eyes and kidney impact. So we certainly care about that as well. Here's the diagnosis. It's two readings of a fasting glucose above 125. Pre-diabetes is 100 to 125. It could be a random glucose over 200 with symptoms. That also is consistent with diabetes. Or an A1C above 6.5, and pre-diabetes is 5.6 to 6.4. We often refer to excellent diabetes control as an A1C below seven, and okay or good control is now below eight. So the American Diabetes Association says you should tailor your A1C level to the individual person. So people on more medicines and who've had diabetes longer and have struggled with higher values, their goal might be less than eight. Whereas a younger person newly diagnosed and not on any medications, you might aim for seven. But we do agree that above nine is poor control. I don't think they're gonna get into that level on your boards, because this is much more about disease management, but this gives you kind of a goal of these things. So implications for practice. Main benefit is detecting impaired fasting glucose to delay the diagnosis of diabetes. And you need to have intensive lifestyle interventions to help people. And this really applies to people who are overweight or obese, people who can make lifestyle changes and people who are willing to make lifestyle changes. So in order to demonstrate the improved outcomes that the task force saw, if a person is not gonna make any lifestyle changes, you could argue there's no value in screening for diabetes. Here's what the diabetes prevention trial entailed. And I mentioned this earlier with the weight loss counseling because a lot of this data was also about the weight loss data. It's also about the data for improving health and exercise. These are the types of programs that are involved. And the DPT aimed for a 7% weight loss in 150 minutes of weekly activity. And they did lifestyle coaches, frequent contacts, 16 sessions with a curriculum, supervised physical activity, flexible maintenance phase to end with restarts of people fall back and this whole network of training feedback and clinical support. Sadly, many communities have less and less access to the diabetes prevention program type interventions. So I think this is something we need to figure out on kind of a national and community level on how to address better. How do we make the right choice for diet and exercise and lifestyle the easy choice? The diet and exercise and weight loss recommendations can get a little, your head can get a little swimming here because I put out a lot of letters, B's and C's and I's. But the gist of it is the greater your risk of problems, like if you're obese or if you have cardiovascular risks, the greater the benefits of the counseling. And the lower the risks, like you have a normal BMI and no cardiovascular risks, the lower the benefit. So this is just a way of kind of showing this all together. For obesity, it's about lifestyle. It's a B for counseling adolescents and adults on lifestyle and lifestyle changes. We talk about screening for abnormal blood glucose for people who are overweight and obese and then doing the intensive lifestyle counseling. And then your people who are overweight or obese and have risk factors, it's a B for the diet and exercise changes and counseling. And for folks with no risks and were normal BMI, that drops to the C to selectively offer. Moving to hormone replacement therapy. This has been established for many decades. I don't know if they even ask you this anymore because it's so well-established, but we generally don't do combined estrogen and progesterone or progesterone alone for, or I'm sorry, or estrogen alone for primary prevention of chronic conditions in post-menopausal people or people who've had a hysterectomy. You would only think of doing estrogen alone if you've had a hysterectomy. If you haven't had a hysterectomy, you have to have estrogen and progesterone. So that might be the type of question they get at. But if you're asked, should you give hormone replacement therapy to a person to prevent chronic disease? The answer is no. The hormones does have benefits. It reduces hot flashes and sweats and all those things. It improves urogenital symptoms, dryness and atrophy. So if you're asked, does it help with menopausal symptoms? The answer to that is yes. It does improve bone density and reduces hip fractures. That's a plus, but we have other medicines we'll talk about that work. Probably reduces colorectal cancer, but if you get adequately screened for colorectal cancer, that might not be important. And it's unclear on the effect on quality of life because we're talking from a preventive service standpoint about doing this for asymptomatic women. So how do you improve the quality of life by improving something that has no symptoms? So the main use of hormone replacement is women who are really having a lot of symptoms and struggling with vasomotor and urogenital symptoms. So if you're asked, would you consider that for a woman for those symptoms? I think the answer to that would be yes. It does have a lot of harms and this is what you have to think about. It increases clots, increases breast cancer. It either increases or has no effect on heart disease. In the Women's Health Initiative, it actually increased it. It increases stroke, it increases gallbladder disease, it increases endometrial cancer. That's where you need the progesterone if you don't give unopposed estrogen if a woman has an endometrium, i.e. a uterus. And it also increases probable dementia. So really, if you add up all the benefits versus all of the harms, there are twice as many harms as there are benefits. And the harms are pretty substantial and the benefits can often be managed more effectively other ways. So if you're asked a question like, should you give hormone replacement to a woman who's experiencing menopausal symptoms? If they give you other lifestyle options, I would start with some of those. So I'd certainly start with lifestyle. You know, if you're having sweats and hot flashes, wearing layers of clothes, having good ventilation, you know, good environment, dealing with those things are better. I mean, as a clinician, I'll advise women to try soy products, which may help. I'm not sure it's the highest level of evidence, but it gives me some lifestyle things to do. And there are even medicines like fluoxetine that can help. And I usually try to do those things before doing hormone replacement therapy because of the harms. So if you're asked about a scenario like this and there's options to try other things first, I would pick that. The other thing is if you're asked to give like unopposed estrogen to a woman with a uterus, the answer is no. And also I'd be really hesitant to do this for women who smoke, because that increases the risks of clots and you start to compound these. So those would be the things I'd be looking for on a question for your boards. Thinking about thyroid dysfunction, this is not thyroid cancer. This is looking for under or overactive thyroid. It's an eye. There's a lot of evidence that the TSH is a reasonable test, but poor evidence that treatment improves outcomes. Remember, this is about screening asymptomatic people. So this is people who aren't coming in and saying I'm gaining weight, I'm tired. I have these different issues that you would expect with an underactive thyroid, or I'm feeling really hot and flushed and my heart's beating fast and you're worried about an overactive thyroid. Those would be clinical reasons to do that, but this is about screening in asymptomatic people. Vitamins to prevent cardiovascular disease and cancer. I'm just gonna give you a hint here for your boards. I would just take the mindset that there really is little to no evidence that taking any vitamin as a supplement improves outcomes. And for some, there's actual harms. So just take that as your baseline statement. Now, there is good evidence that getting vitamins through lifestyle is important. So getting your antioxidants through healthy diet or the fish oils through eating fish, those are good for you. But the moment we try to take this and put it into a pill, there just isn't much evidence about that. And the same applies for vitamin D. So we'll talk about that. And I know that vitamin D is such a topic that comes up all the time and there's every now and then evidence showing it helps, but there's also evidence showing it does the opposite effects. So that's where the task force kind of ends up on vitamin D. And thinking about vitamins, anyone who has a deficiency, that's a different issue. So you do wanna address and deal with deficiencies. So as you're looking at the question, if they're asking you, someone who has a vitamin D deficiency, should you replace it? Yes, you should. If you're asked, should you screen for vitamin D? No, you shouldn't. Or if you're asked, should people routinely take vitamin D? I would say no, unless they ask, does like the National Health Service in England recommend it, which they do, but task force would say no. So it's actually a D for beta carotene and vitamin E, and it's an I for multivitamins or other supplements to prevent cardiovascular disease or cancer. And it's an I for single or paired nutrient supplements other than beta carotene and vitamin D, E, which is the D. So the first one's about multivitamins, the second one's about individual supplements. And the reason that beta carotene has a D is in the studies that actually increased lung cancer and vitamin D, vitamin E actually increased prostate cancer. It's also an I, as I said, to screen for vitamin D deficiency. So this is different than just routinely taking the vitamin D, which was the last recommendation. This was about measuring vitamin D levels. And we talk about vitamin D because it's in the news all the time, and there's a lot of promotion of vitamin D. And we know that low vitamin D levels are associated with the causes of low vitamin D are things like low UVB exposure, older age, and obesity. And we know that people who have a low vitamin D level have all of these bad outcomes, including death and fractures and falls and cancer and cardiovascular disease and infection. We even talked a little bit about should you take it to prevent COVID? But what's really hard with vitamin D is to tell what is causal versus associative. So for most people to have an adequate vitamin D level, you've gotta be outside for like 20 minutes a day. So is it really the fact that most people who have a low vitamin D level have that because they're not outside for 20 minutes a day, which you really should do, and people who aren't outside for some time, they're not active enough and they have bigger risk for chronic diseases and other things. So getting at the causality versus the association is the major challenge with vitamin D. There's not a great consensus on how to define it. I know the standard lab sheets that I have for patients say you're low if it's below 30. Well, a large part of the population has a vitamin D below 30, like nearly half. And there just isn't data that everyone taking vitamin D improves an outcome. If half of the population has this so low, then we should be able to demonstrate studies of giving people vitamin D changes outcomes. And we struggle with that. So National Academy of Medicine has said that 97% of the population will have their vitamin D needs met if their level's 20. So they define a low value as 20. And very low levels, well, that might be a bigger issue. So I would definitely look for that. So 5% of people had a value less than 12, about 18% had a value between 12 and 19. Thinking about benefits in early detection and treatment with vitamin D, there's no studies directly evaluating the benefits of screening for vitamin D. There's a number of studies, RCTs and case control report on the effectiveness of treating vitamin D deficiency. And if you look across all of them, like there's been eight trials that looked at mortality and you aggregate them, there's no difference in mortality. If you aggregate the six trials on fractures, there's no difference in fractures. The five trials on diabetes, there's no difference in those trials. And the two trials on no difference in cardiovascular disease and two trials with no difference in cancer. So if you aggregate all these trials, there aren't differences. Now there was one big trial that showed that taking vitamin D lowered your mortality. There was another big trial that showed that by taking vitamin D increased your mortality. So that's where, looking at the evidence as a whole, it doesn't seem to be beneficial. And we don't know this. So the task force gives it an eye saying we need more evidence. Chronic kidney disease is also an eye. This was recently updated. I think it was just this year, but this year's update also gives it an eye. So it just hasn't changed. And there's insufficient evidence recommending for routine screening for chronic kidney disease. There are groups like the American Diabetes Association and some of the hypertension guidelines say you should check this routinely to see if people with diabetes or people with hypertension have kidney disease. And this is often checked as a part of monitoring medications. So that's a little difficult to sort out what's what with that. Let's move to musculoskeletal disorders. So first with osteoporosis. So the task force does recommend screening women 65 and older for osteoporosis. And this is with bone density measurement. And women younger than 65 who have risk factors that put them similar to a 65 year old woman. And it's an eye for men of all ages. So the task force has repeatedly tried to look and say, okay, should we be screening men? Now we should get bone density and look for osteoporosis in people who have like a fragility fracture or people who have high risks like they've been on prednisone a long time. But this is talking about screening in the general population. The way you calculate a woman under 65's risk for a fracture is you use a scale, a score called a FRAX score. This is very similar to like your 10 year cardiovascular risk calculator. And you're looking for a score that puts a woman at a similar risk as a 65 year old woman. You're not gonna need to know how to calculate that or anything like that. Or if you do, I wouldn't bother. Well, you won't, because it's looking up all these different tables of different cohorts of people to get to the number. It's very complex. How often you screen? We don't know the answer to that. We do know that it takes at least two years for your bone density to change. So you should not do an annual screening test. In one study actually showed no benefit from repeated bone mineral density measurement in woman whose initial density was normal. So if they start asking you how often to do it, generally for most people, every three years or so is fine. But I think it'd be a reasonable choice if they say a woman has a completely normal bone density or her bone density is zero, which we'll talk about in a second. She probably doesn't need one ever again. And if they say every one year, the answer is wrong. Don't pick that. So age is your biggest risk factor for fractures with osteoporosis. The bone density, the dexa, the hip is the best studied. You can also do ultrasounds, but most often we think of the dexa scan. And treatment for women with osteoporosis can reduce fractures by 30 to 50%. And the main treatments are bisphosphonates, parathyroid hormone, naloxone and estrogen. It really boils down to bisphosphonates and parathyroid hormone. In practice, naloxone has a lot of side effects. And I show that to you when talking about medicines to prevent breast cancer. But you might use this on a woman who you wanna prevent breast cancer and you're worried about her bone density. And we just talked with hormone replacement therapy about the harms of estrogen. So that's not really routinely done. And I think bisphosphonates or parathyroid hormone are really the true answers for osteoporosis prevention. There are two scores. There's a T-score and a Z-score. The T-score compares your bone density to a healthy 25-year-old. Z-score compares your bone density to a woman or a person of similar age, gender and ethnicity. I've always thought it makes more sense. I've always been confused. Why do you use a T-score? Why would you compare an 80-year-old person to a 25-year-old person? But comparing an 80-year-old to an 80-year-old, it's really hard to figure out, what do I do with this? So we really want kind of a benchmark. And we've just arbitrarily said that a 25-year-old ethnic matched man or woman is the benchmark. And the values are these numbers, like one, the negative, whatever. And these numbers represent standard deviations. So this is, so if your bone density is one, that means you're in the top one standard deviation of bone density for a 25-year-old person your age. So when we're thinking about osteoporosis, it's almost always negative numbers. So a negative one to negative 2.5, that's standard deviations off of a 25-year-old. That's osteopenia or bone thinning. And osteoporosis is more negative than negative 2.5. And a decrease by one standard deviation increases your fracture risk by 1.5. So osteopenia, you don't necessarily do medicines. Even osteoporosis, you don't necessarily do the bisphosphonates or parathyroid hormone. You often can start out with lifestyle, getting enough calcium and vitamin D, exercising, and you also look at other people's risk factors. So calcium and vitamin D to prevent fractures. This is not to treat people with osteoporosis or osteopenia or to treat people with deficiencies. This is to prevent fractures. The key thing to know is the bottom, which is Women's Health Initiative randomized women who are postmenopausal to get 400 units of vitamin D and 1,000 milligrams of calcium, and it didn't change any outcomes. There were no less fractures than women who took that every day. So the task force was able to give a D to taking 400 units of vitamin D or less, or 1,000 milligrams or less of calcium. Now you'll see right above it, it's an eye for higher doses. There just haven't been studies. So did the Women's Health Initiative pick the wrong dose? Should it be 1,000 units of vitamin D and 2,000 milligrams a day of calcium? I mean, we don't know. There is insufficient evidence on that. And then for men and premenopausal women, we also have an eye because we don't have studies on them. The Institute of Medicine does talk about making sure people get enough of these things in their diet. And I would argue that it's through lifestyle. People should get about, women about 600 units of vitamin D. If you're under 70, 80, if you're over 70, most people can get that through diet and through getting outside for 20 minutes. But if you're gonna replace it, most often we have people take 800 to 1,000 IUs daily. There have been people giving 50,000 IUs weekly for eight weeks. And I remember learning that and being taught that earlier in practice. I don't like that because at least in one of the trials of replacing vitamin D, they gave people 500,000 units once a year. That sounds like an extreme amount, but remember vitamin D is fat soluble. You get this and it stays in your body for a while. So the 50,000 once a year is not that far off from 50,000 or 500,000 once a year is not that far off from 50,000 every week for eight weeks. In that one trial where people got 500,000 once a year, they were looking at fall and fall risk and actually increased falls and caused more harm. So I extrapolate a little from that evidence and in practice tend to give 800 to 1,000 units a day. And above 4,000 starts to get to be unsafe because as I said, it is a fat soluble vitamin and builds up. And Institute of Medicine recommends that women get 1,000 milligrams of calcium if you're under 50 and 1,200 a day and 1,000 for men. And most of this can be done, as I said, through lifestyle and diet. Fall prevention, task force gives a B recommendation for adults over 65 to screen for falls and then give exercise interventions for people who are at increased risk of falling. And then it's a C for these multifactorial interventions. So this sounds really weird because it's a B for exercise interventions and the multifactorial interventions include exercise. So why is that a lower level? The fact is just the evidence, the multifactorial interventions seem to have a smaller net benefit than the exercise interventions in the studies. Now, is that because they're not effective or less effective than exercise? I'm not sure that that's the case. It might be an artifact of the evidence. But a good way to think about it, multifactorial evidence is things like assessing all these other risks like home assessments and hearing and vision. And those are important and as a clinician, you wanna think about that. But if you're thinking from a practice standpoint, should we routinely do multifactorial interventions on everyone? No, I don't think we should. We'd start with exercise. And then the people who are more worried that might have other contributing factors other than just balance and muscles, you'd think of the multifactorial interventions. And then the task force actually gave a D for taking vitamin D because prior to 2018 and 2014, it actually gave a B for taking vitamin D to prevent falls because there were some early studies that showed benefits in preventing falls. And then between the 2014 and 2018 recommendation, the new studies came out like that one I mentioned to you about 500,000 units once a year showing that actually increased falls. So suddenly the task force became more convinced that this probably really isn't beneficial. So on your boards, it's a D to take vitamin D to prevent falls, it's a B for exercise and selectively think about who to give multifactorial interventions. Let's move to talking about oral vision and hearing disorders. So in terms of dental, the task force gives a B to prescribe oral fluoride to children greater than six months of age with fluoride deficient water, gives a B to apply a fluoride varnish to teeth of children at age of primary tooth eruption and gives an I to recommend for routine assessment of preschool children by primary care clinicians for the prevention of dental disease. So this is about primary care doctors, counseling and looking at teeth and thinking about dental caries. It's not necessarily about seeing a dentist. And I think if you look at like bright future recommendations they do recommend that kids routinely see dentists. So if you're asked, should a kid see a dentist? I would say, yes. If you're asked, should a primary care clinician routinely assess preschool children for dental disease? I would say there's insufficient evidence. And I wanna just put a caveat here. I've tried to use the right language, but it's easy to say that when there's an I statement, you shouldn't do this in practice. I'm trying to not say that because technically when it's an I, it just means there's insufficient evidence. Now for clinicians like myself routinely, we do not do I, do services that have an I statement because we don't have certainty that doing it is improving outcomes. But read the question carefully because technically speaking an I, an absence of evidence is not evidence of an absence of benefit. So technically speaking, could there be studies that show that this works great in primary care and in the future, the task force changes its recommendation? Absolutely. So try to read a little bit and be a little bit careful about that of distinguishing the I and the D. But if you're having trouble remembering is it an I or a D, do your best and it'd be better to differentiate between the two. But if you can't, if you can only remember sort of yes or no, I'd put the I and the D into the no, you don't routinely do it. Here's about oral health in children and adolescents and screening to prevent. This is a draft from 2023. I'm just showing you, it's an update to what I showed you on the slides before. The guidelines are the same. It's still an I, insufficient evidence, although they looked a little bit more detailed at the types of interventions and the type of outcomes for children, but still found insufficient evidence. And they actually look for adults. Should we do this in adults? This was a new thing in May, 2023, also insufficient evidence for this. As I mentioned, dental health visits are recommended. People should brush, they should floss, they should use fluoride toothpaste and you should have fluoride supplements in your water. And if you don't, then kids should be prescribed fluoride to prevent dental caries. Thinking about vision, the task force gives an I statement for screening for glaucoma. There are recommendations to refer high risk people on other grounds and the task force acknowledges this, but in terms of routinely screening everyone for glaucoma, we don't have evidence that this preserves vision and changes health outcomes over time. Screening can find increased pressure, but it's unknown whether this improves vision. And then in terms of screening for visual acuity in older adults, it's also an I, there's insufficient evidence. Once again, if you're asked a question and someone's an older person, they're falling at home and they give you some clues in their story that they might have troubles with their vision, maybe you should do that multi-component fall prevention intervention, which would include a visual assessment. But I would read those questions carefully. If you're asked, should you routinely screen older adults for visual acuity issues, there's insufficient evidence for that. Thinking of kids, the task force does recommend screening children once between the age of three and five to look for amblyopia or risk factors. This is your eyes not tracking together. It's common, two to 4% of kids have this. Early detection and treatment with patching and medicines like cycloplegics and eyeglasses does improve visual acuity over time. Under three, there's insufficient evidence. And practically speaking, trying to figure out if a child under three has amblyopia, I don't know how I would even do that exam on a child. They just can't follow instructions enough. So I think it'll always be three to five year old type of a recommendation, unless we get some new technology. And thinking about hearing, this is about screening, like asking adults routinely about hearing issues or doing hearing tests and the task force found there is insufficient evidence. I will say that asking about hearing is supposed to be part of the Medicare wellness through CMS. So many clinicians do this. If you're asked, does the task force recommend it? I'd say there's insufficient evidence. If you're asked, does Medicare ask clinicians to mandate clinicians do this as part of the annual wellness visit, I would say yes. Let's move here to maternal health, and we'll go over the different recommended services from a task force perspective. Obviously, there's a lot of nuance to the practice of obstetrics, and there's a lot of evidence in managing folks, but this is much more about your primary and your secondary prevention of pregnant people. And remember, I've talked about this on a lot of different recommendations already, things like smoking, cessation screening and counseling, and the perinatal depression. So we already have a lot of those things. I'm not gonna repeat those, but checking for different infections like hepatitis B, it is recommended, checking for syphilis, checking for HIV and RH incompatibility. These are all just standard parts of prenatal care. We should be counseling pregnant people. So this is about nutrition, about breastfeeding, about tobacco, alcohol, sexual behavior. The lap, shoulder belts, infant safety seats, these are kind of come out more with bright futures as opposed to US Preventive Services Task Force. Some early versions in the 90s of the task force manual did suggest doing this, but pregnant people should wear lap and shoulder belts. That actually protects the mother and the unborn child. And counseling about infant safety seats is very important for as people get ready to become new parents. To prevent neural tube defects, it is recommended. It's an A. This is some of the best evidence that's there. It's gotten a lot better with folic acid being added to bread. But in general, the guideline says that women who might become pregnant should take folic acid. So this is hard to know. Women of pregnancy age, are they going to get pregnant? Sometimes we don't know this. So you could argue that all women of pregnancy age should take a multivitamin with folic acid in it. Neural tube defects occur early in the first trimester. So you really want to be on these medicines in the first couple of weeks of getting pregnant. So that's some of the issue. And high-risk women should take a much higher dose instead of just what's in a prenatal vitamin, they should be taking four milligrams a day. And high risk is defined as having a prior pregnancy with a neural tube defect. So that's a small subset of the population. Screening for gestational diabetes. It is recommended, it's a B, to screen people at 24 weeks of pregnancy. Finding this and treating it reduces macrosomia, birth trauma, neonatal hypoglycemia. You do this with a one-hour glucose tolerance test. It also reduces preeclampsia and shoulders getting stuck. That's the birth trauma. Aspirin to prevent preeclampsia. So pregnant persons at high risk for preeclampsia should take 81 milligrams of aspirin a day after 12 weeks of gestation to prevent preeclampsia. And high risk includes a prior history of preeclampsia, multi-fetal gestation, chronic hypertension, diabetes, kidney disease, or autoimmune diseases. And this has been shown to reduce preeclampsia by 24%, preterm birth by 14%, and intrauterine growth retardation by 20%. For clinicians, not having a patient with preeclampsia is much nicer. When I used to do deliveries, my pregnant persons who had preeclampsia, you know, this is something that you lose sleep and worry about how the pregnancy's gonna go. So this is an important preventive service. Group B strep screening is universally recommended. This is by the CDC, not by the task force. It's all pregnant people at 35 to 37 weeks. And, you know, if it's positive, you give antibiotics during labor, and that reduces newborn sepsis. And it's not necessary if you're gonna plan a C-section. Screening and prevention not normally recommended in pregnancy, screening for bacterial vaginosis to prevent preterm labor. It is associated with preterm labor, but there's no data, or there is data, that actually when you screen women, you're not changing these outcomes in low-risk women. And there's a lot of over-diagnosis and over-treatment. High-risk women, we're still a little bit unclear. Anemia screening, there's insufficient evidence. It is normally part of obstetrical care. It's usually done, but it's not a preventive service where the task force said there was adequate evidence to routinely recommend it. It's a deed for genital herpes in asymptomatic pregnant persons, and also for screening just from an STI standpoint, all adolescents and adults. Genital herpes, if you have an active case in labor, that can be a problem, but screening has a lot of false positives. The test to identify it in people who don't have active lesions is a challenge, and there's lots of false positives, and there's nothing to do if you don't have active lesions at the time of labor. And screening for elevated lead levels during pregnancy also has an eye. Thinking about child health, so it is recommended to screen all newborn infants for hearing loss. Finding this improves language outcomes, addressing that early on. It used to be a D for screening kids for lead who were low risk, and the task force moved from a D to an I after the issues of lead in the water in Michigan, and they moved to an I because it was always an I for screening for kids who were considered moderate to high risk. And with Flint, Michigan, the task force really decided that our ability to say who's at high risk and who is not, we don't have an ability to do that. So we got rid of the D for the low risk and really said that there's insufficient evidence to recommend for or against this. I would think about this preventive service much more of a population health level. I lived in Flint, Michigan. Absolutely, I would be screening kids for this. Or if kids are in older houses or they have lots of exposure to lead, their parents do lots of pottery or things that bring lead into the home. Those would be things I'd be thinking about. But for your boards, I think lead is a problem, but whether to routinely screen all kids, we don't know whether to do that or not. Screening for autism is also an I and sufficient evidence to recommend for or against this. This is one of these hot button items just from a health and a public health standpoint. Autism is relatively common and its incidence and prevalence is increasing. But from an evidence standpoint, here's what we know that the screening instrument, the MCHAT is pretty good. It can actually identify kids with autism. It does only have about a 50% positive predictive value when kids are positive, but the other kids who screen positive often have a lot of different language developmental delays. There's also evidence that treating kids with autism improves outcomes. They do better with social and family relations and with school and with learning. So when I say both of these statements, you're probably thinking, well, why is the task force not recommending this? The screening service would be screening 18 month olds who have no symptoms. All of the evidence on treating autism is on kids with an average age of five years of age. And it's also from kids who are detected through symptoms. So it's called autism spectrum disorder. So kids whose parents and teachers and others that the clinician are worried about a kid because of the symptoms they're exhibiting are going to be different than the 18 month old who has no symptoms that you're only detecting on an MCHAT screening tool. So when you put these two bits of evidence together, the task force doesn't have much confidence yet that that pathway works. And that's how they get to the I statement about screening for autism. Screening for scoliosis is also an I. At one point it was a D, but there have been some recent studies that show bracing can decrease curvature progression with mild to moderate curvature. This is an intermediate outcome. We don't know if this improves health outcomes, quality of life, other factors for kids. So it wasn't enough to move it to a C or a B, but it was enough for the task force to say, well, there's some evidence of a change in an intermediate outcome. We need more evidence. And so they made an I statement, which is a call for more evidence. I'm going to close with this. This was a recent study. This is a thought analysis. It was done in 2021. They did it in 2004 as well. And it says, well, how much time would it take to deliver all the task force A and B recommendations if a clinician had an average panel of 2,500 patients? And the answer was, they said it would take 8.6 hours per day for a clinician to do this. And most primary care clinicians do more than just prevention. They're doing chronic care and acute care and all the other issues people come in with. When you look at the hours per day, a lot of that is with counseling. So it is assuming that primary care clinician does everything like that. 25 hours of face-to-face counseling for adolescents who have a BMI in an obese range, which is not right. That's why I call this a thought experiment. The two things that this tells me, and I want to close with this, and it's the reason I closed with it for this talk, are three things. One is prevention is hard. This is not easy, takes a lot of work, and we need to do it well. The second is it does take a team. There's all these pushes for the interdisciplinary teams, and this is really the evidence that shows why you need an interdisciplinary team. A primary care clinician can't spend 131% of their time delivering preventive services. It's just not going to happen. We need a whole range of teams, and the evidence supports that. The Diabetes Prevention Program is not being done by a clinician. It's being done by nutritionists and personal trainers and other team members who can do it better than a clinician can do it. And then the other thing that this tells me is how important it is for us to know what works and what doesn't work. So this is why we need methods like the U.S. Preventive Services Task Force has. And I always used to say that the task force is about helping us to know what we know and know what we don't know. And knowing what we know can allow clinicians to focus in and use their time in the most effective way that's going to have the greatest value. And knowing what we don't know is going to help to create a national agenda on the research we need to improve the evidence on preventive care. So this is great evidence and argument for these things. I'll close with that and just wish you all good luck. And I said throughout here a lot, I tried to interject on how to think about answering these questions. You're smart. Use your test-taking skills. It's not about memorizing everything on all of these slides. There's a lot of detail on here that probably is more in-depth than you're going to need for your boards. I'm really trying to share the concepts with you. So stick with the concepts and use that and think about everything that you've learned and you'll do just fine. Good luck.

evidence-based preventive care

clinical medicine

lifestyle counseling

screening tests

immunizations

chemoprevention

shared decision-making

individual risk factors

ASCEND study

ASFRE study

cardiovascular disease

aspirin use

U.S. Preventive Services Task Force

respiratory diseases screening

colon cancer screening