research and quality, Dr. Wolfe assists the USPSTF in the formulation of recommendations on preventive services provided in primary care settings. She is the lead author on several evidence reviews commissioned by the USPSTF. Dr. Wolfe has received several awards for her work at AHRQ, including the Secretary's Award for Meritous Service. Dr. Wolfe completed a family medicine residency at the University of Maryland and a preventive medicine residency at Johns Hopkins University. She received her Master of Public Health at Johns Hopkins as well with an emphasis on health policy and planning, maternal and child health. Our second speaker will be Dr. Carolyn Mangione. Dr. Mangione is the Chief of the Division of General Internal Medicine and Health Services Research at the David Geffen School of Medicine at UCLA. She is also a professor of public health, co-director of the UCLA Resource Center for Minority Aging Research, Associate Director of the UCLA Clinical Translational Science Institute, and is Vice Chair of the US Preventive Services Task Force. Her research focuses on the influence of health insurance, benefit design, and health system interventions on diabetes outcomes, diabetes prevention, and health disparities. Dr. Mangione is a primary care physician at UCLA and is a member of the National Academy of Medicine. Our third speaker will be Dr. Tina Phan. Dr. Phan is the Associate Scientific Director for the USPSDF Program at the Agency for Healthcare Research and Quality and a previous medical officer with the program from 2013 to 2020. She is a board certified physician in preventive medicine. Prior to joining AHRQ, she worked at the Suffolk County Department of Health as Director of Communicable Diseases and Director of Performance Improvement for their county-operated health centers. She completed a clinical internship in obstetrics and gynecology and residency in preventive medicine at the Stony Brook University School of Medicine and received her Master of Public Health degree from Columbia University. It's my distinct pleasure to turn this time over to them now. Thank you so much. Thank you so much, Karen. Thank you all for joining today to hear an update about the US Preventive Services Task Force. Our plan for the next hour is for me to do a quick introduction about the task force for those not familiar with the task force and then turn it over to Dr. Carol Mangione, who's the Vice Chair for the task force, for an update on recent postings and publications from the task force and a detailed presentation about the task force's recommendations on lung cancer and colorectal cancer screening. Then Dr. Tina Pham will share more about the task force's efforts in making recommendations for diverse populations. And then we'll plan to answer all the questions at the end. So the task force is an independent body of 16 national experts who volunteer for this service. They're experts in prevention and evidence-based medicine. They make evidence-based recommendations about clinical preventive services, including screening, counseling on healthful behaviors, and preventive medications. The recommendations address only services offered in primary care settings or services that are referred by a primary care clinician. The recommendations from the task force apply to adults and children with no signs or symptoms of the condition. The task force recommendations generally address routine use in people not at significantly increased risk. The task force looks for evidence as well when it's available that might provide information about how recommendations may differ or not for specific groups of people. The task force recommendations are based on the evidence of both the benefits and harms of the service and an assessment of the balance of benefits and harms. The task force does not consider cost or coverage of providing a service in its assessment. The task force recognizes that policy and coverage decisions involve considerations in addition to the evidence of clinical benefits and harms. All the information about the task force, including all of the recommendations and more than 80 of the recommendations from the task force and all of the reviews that the task force uses to make the recommendations are available on their website. They're on your screen, USPreventiveServicesTaskForce.org. On this website you can also sign up for email notifications whenever the task force posts something new. You can also go to the LinkedIn page for the task force. The task force works with multiple organizations in developing their recommendations. The agency for which I work, the Agency for Healthcare Research and Quality, or AHRQ, provides scientific, technical, administrative, and dissemination support. The EPCs, or Evidence-Based Practice Centers, conduct the systematic reviews that the task force uses in making their recommendations. And multiple federal health agencies and professional societies, including ACPM, provide feedback on draft materials and help with disseminating the task force's recommendations. And throughout the process, subject matter experts are consulted. In addition, the public comments are solicited for all draft research plans, systematic evidence reviews, and draft recommendations. And the task force carefully considers all submitted comments in finalizing its recommendations. For your reference, here's an overview of the recommendation development process. For more detail, I encourage you to go to the task force's website. As I mentioned, the task force considers evidence on both the benefits and harms. When it makes a recommendation, it considers the certainty of that overall evidence on benefits and harms and the magnitude of the balance of benefits and harms. Here's an analytic framework from the task force. This is a generic one on screening for a disease. For every recommendation, the task force starts with an analytic framework like this. And this analytic framework helps to communicate the questions that the task force needs answered with evidence to make a recommendation. It also makes clear that it looks at the adverse effects or harms of screening and treatment for early disease, as well as the outcomes that they're looking for. When the task force makes a recommendation, it looks at the magnitude of the benefits and harms, determines the balance of the magnitude of net benefit. And when the evidence is not sufficient or low certainty, the task force does not use expert opinion, and they issue an I statement, which is not a recommendation. The letter grades that are assigned to each recommendation are based, as I mentioned, on the magnitude of net benefit and the certainty of net benefit. So, for example, if there's high certainty that a preventive service provides a moderate net benefit, the task force issues a B grade. And here you'll see the definitions of what the grade means. Essentially, an A and a B graded recommendation are recommendations for clinicians to provide that service to their patients. A D grade is a recommendation against providing the service. A C grade is a recommendation to selectively offer or provide the service. And an I grade means that the current evidence is insufficient to assess the balance of benefits and harms of the service. So I'll turn it over to Dr. Carol Mangione, vice chair for the task force. Thank you, Tracy. I think your clicker needs to go off for mine to work. Okay, great. Thank you for this opportunity to talk to you about some of our recent updates. I'm going to start my presentation by telling you about some of our draft research plans that are currently in progress. In the schema at the bottom of the slide, you can see how we move a topic along from draft phase to final research phase, then into the draft recommendation and evidence review to our final recommendations and evidence review. And this pathway is followed for all of our recommendations. So important recommendations that we have in progress right now are for breast cancer screening, screening for latent TB infection among adults, prevention with menopausal hormone therapy as primary prevention for chronic conditions, screening counseling and preventive interventions for oral health, screening for autism, screening for COPD is in final research plan. So it's gone one step beyond where the previous slide was. Also in this grouping, we have screening for impaired visual acuity and glaucoma, screening for obstructive sleep apnea, screening for depression, anxieties, and suicide risk. These are two separate recommendations. One's for adults and pregnant person and one for children and adolescents. Screening for eating disorders, screening children and adolescents for pre-diabetes and type two diabetes, screening for skin cancer, and screening in non-pregnant persons for syphilis infection. A few more where we have the final research plans is screening interventions for dental caries in children younger than age five, use of statins to prevent cardiovascular disease, use of aspirin to prevent cardiovascular disease or colon cancer, preventive medications in the class of vitamins, minerals, multivitamins to prevent cardiovascular disease and cancer, and then counseling for healthy diet and physical activity for cardiovascular disease prevention among low-risk adults. We have a number of draft recommendations that are currently in progress. One is aspirin use to prevent morbidity and mortality from preeclampsia. Colon cancer screening today moves from draft to final, so it was published this morning. Screening for gestational diabetes, behavioral counseling interventions for healthy weight and weight gain during pregnancy, screening for atrial fibrillation, screening for chlamydia and gonorrhea, and screening for pre-diabetes and type two diabetes among adults. I'm now going to show you the text on some of our screening recommendations, and these new recommendations are ordered by the grade, so we'll first talk about the grade A1s, B1s, and proceed on from there. We have a new final recommendation for interventions for tobacco smoking cessation in adults, including pregnant persons, and this is a grade A recommendation. We recommend that clinicians ask all adults about tobacco use, advise them to stop using tobacco, and to provide behavioral interventions and FDA-approved pharmacotherapy for cessation among non-pregnant adults who use tobacco. For pregnant persons, we're not recommending pharmacotherapy at this time, because the evidence is insufficient to assess the balance of benefits and harms of pharmacotherapy interventions. That's why that one part of the recommendation is graded as an I for pregnant persons. And then finally, we have an I that the current evidence is insufficient to assess the balance of benefits and harms of electronic cigarettes for tobacco cessation in adults, including pregnant persons. Another recent recommendation that was published earlier this year is the lung cancer screening recommendation. I'm not going to read it to you now, because a big part of my talk will take a deeper dive on this one. This is a B recommendation. We have a number of other B recommendations. We recommend behavioral counseling for all sexually active adults and adolescents who are at increased risk for sexually transmitted diseases, and that's a B. We also recommend offering or referring adults with cardiovascular risk factors to behavioral counseling interventions to promote a healthy diet and physical activity, and that also is a B. And we recommend screening for hepatitis B virus infection in adolescents and adults at increased risk for infection. There's one D recommendation that has recently been published, and this is screening for asymptomatic carotid stenosis, carotid artery stenosis. So we're recommending against this screening. We have a number of I recommendations. One of our I recommendations has to do with high blood pressure in children and adolescents, and here we conclude that the current evidence is insufficient to assess the balance of benefits and harms of screening high blood pressure in children and adolescents. We also concluded that the current evidence is insufficient to assess the balance of benefits and harms of screening for hearing loss in older adults, and we also found that the current evidence was insufficient to assess the benefits and harms of screening for vitamin D deficiency in asymptomatic adults. So now I'm going to talk in more depth about two of our recommendations. The first is the screening for lung cancer final recommendation that was published in March of this year. Lung cancer is the second most common cancer and the leading cause of cancer death in the United States. And I think with this group, I probably don't have to tell you that in 2020, over 200,000 persons were diagnosed with lung cancer and 135,000 people died from the disease. As people in prevention, we all know that the most important risk factor for lung cancer is smoking. Smoking accounts for 90% of all lung cancer cases, with a relative risk of lung cancer approximately 20-fold higher in smokers compared to non-smokers. Age is also a risk factor for developing lung cancer, and the median age of diagnosis for lung cancer is 70 years of age. So why screen for lung cancer? Lung cancer has a very poor prognosis, with an overall five-year survival rate of 20%. And we know that if we can find lung cancers in early stages, that they have a better prognosis, mainly because they're treatable by surgical resection. This study by Aldridge partially informs our new recommendation, as does the Nelson trial. So I wanted to slow down for a minute and talk to you about this study. In this study, and this is a study that came from a population-based cohort study in the United States, in the southern part of the United States. And what you have on the y-axis is the frequency, or how often, people are in different PAC year categories. So on the x-axis, you have the PAC years. The orange histogram is the distribution for African Americans, and the pale blue histogram is the distribution of PAC years for white persons, and then the dark bars are the overlap zone. On the right-hand side of the slide, what you see is the cumulative distribution function of PAC years for people who are diagnosed with lung cancer. And you see the shift to the left, which suggests, or supports, that African Americans develop lung cancer at lower rates of PAC year use. This is a table from the same paper, and it is a table of people who developed lung cancer from the same cohort, and it shows the percentage of whites and African Americans who would have never been eligible for screening at our previous cutoff of 30 PAC years. And it's 37% for whites, and it is 67% for African Americans. So this creates, potentially, a disparity in screening, because the criteria for screening don't align well with the average PAC year use among African Americans with our previous version of this recommendation. So to update our recommendation, we did the following things. We had a systematic review that we commissioned, and it focused on the accuracy, the benefits, and harms of screening for lung cancer. The review also looked at variations by subgroup, by number and frequency of low-dose CT scanning, and by the protocol used to classify the lung nodules. The systematic review also helped us determine whether the use of risk prediction models to identify adults at higher risk for lung cancer mortality improves the balance of benefits and harms. To inform our new recommendation, we also commissioned a CISNET model, and this model specifically looked at the differences in start and stopping ages, differences in screening intervals, differences in PAC year eligibility, and the relative benefits and harms of different screening strategies based on lung cancer risk. Our updated recommendation changed to offering screening starting at 50 years of age instead of 55, and we also lowered the PAC years to 20 PAC years rather than 30. I'm going to show you this next to the other recommendation, the previous one, so we'll skip it here and go right to this. So if we're really looking at the changes from 2013 to the present, in 2013 we recommended screening adults age 55 to 80 who had a 30 PAC year smoking history and either were current smokers or had quit within the past 15 years. And for this group, we recommended annual screening with low-dose CAT scans. The new recommendation has a broader age band, recommending adults between 50 and 80 years who have a 20 PAC year smoking history and are either current smokers or have quit in the last 15 years. And again, the recommendation still is annual screening for lung cancer with low-dose CAT scans. So what evidence did we look at to make this determination? And we really were influenced by two trials that were well-powered. The first is the NLST, which had 53,000 people in it, and it showed a relative risk reduction of 20%, and this study looked at annual screening for three years. More recently, the Nelson trial published, and it has 15,000 patients, and it has an IRR of 0.75 over 10 years of follow-up. And the screening intervals here were one year, then two years, then two and a half years. Our sysnet models also looked at screening intervals and determined that annual screening with low-dose CT scans gave greater benefit in decreasing lung cancer mortality and in life years gained compared to biannual screening. So it's good to take a moment and to look in a little more detail at the Nelson trial. So the Nelson trial enrolled people 50 to 74 years of age with a lighter smoking history. So this gave us empiric clinical trial evidence to support lung cancer screening in people with a lighter smoking history and at an early age. So screening for lung cancer in persons with lighter smoking histories and at an early age increases the benefit of screening. When we look at this new set of targets for who to screen, we see a reduction, a mild reduction in lung cancer mortality of 13%, averting 503 lung cancer deaths and leading to almost 7,000 life years gained compared to the previous recommendation where there was a 9.8% reduction in mortality and 381 deaths averted per 100,000 population. We also looked at harms associated with low-dose CT screening and these harms really come from three categories. One is false positive results leading to unnecessary tests and potentially invasive procedures, incidental findings that also could lead to further testing, and short-term increases in distress due to indeterminate results, over-diagnosis and radiation therapy. So in the NLST, the false positive rate was 26.3% at baseline, 27% at one year, and almost 16% at two years. By using the Lung RADS classification system, you can decrease the false positive rate. Among persons screened, the percentage who ended up with a needle biopsy for a false positive result ranged between 0.09% and 0.56%, with complication rates ranging between 0.03% and 0.07%. Surgical procedures for false positive results were reported between 0.5 and 1.5% of all screened patients. When thinking about the harms, one thing that's very important to note is that there was a wide range of reported screening-related incidental findings, from almost 4% to 40%. The SysNet modeling found a comparable proportion of excess or over-diagnosed in screen-detected lung cancer patients with lifetime follow-up between our two recommendations, what we call the 50-80, 20-15, and the old recommendation that was 55 to 80 and 30-pack years, both coming in at approximately 6%. The radiation exposure of one low-dose CAT scan is less than the average annual background radiation exposure in the US. So the USPS concluded with moderate certainty that annual screening for lung cancer with low-dose CT had a moderate net benefit in persons at high risk for lung cancer, based on age, cumulative exposure to tobacco smoke, and years since quitting. The moderate net benefit of screening depended on limiting screening to persons at high risk, the accuracy of the image interpretation being similar to or better than what was found in the clinical trials, and the resolution of most false positive results with serial imaging rather than diagnostic invasive procedures. So when thinking about this recommendation and applying it in practice, we have to think about the screening eligibility. And it's important to note that the task force does recommend discontinuing screening if a person develops a health problem that substantially limits their life expectancy or the ability or willingness to have curative surgery. We never wanna forget that smoking cessation counseling is so critically important and the most important intervention that we have to prevent lung cancer. Finally, this is a complicated decision and we recommend a shared decision-making framework so that clinicians and patients can discuss risk for lung cancer and whether the patient wants to be screened. And then finally, it's very important to have standardization of the low-dose CAT scan screening and the follow-up of abnormal findings. So when we think about this recommendation and the framework of health disparities, screening for lung cancer in persons with lighter smoking histories and at an early age may help to partially offset or ameliorate disparities in screening eligibility. Black persons who smoke have a higher risk of lung cancer compared to white persons, and the risk difference is more apparent at lower levels of smoking. Latinx or Hispanic persons who smoke accumulate fewer PAC years than white persons who smoke. Our new strategy would increase the relative percentage of persons eligible for screening by 87% overall. And the percent increase is 78 for Latinx people, 105 for non-Hispanic black adults, and 112 for Hispanic adults when compared to our 2013 recommendation. I'm now going to move on and talk about colorectal cancer. And as I mentioned, this recommendation was published today. Colorectal cancer is the third leading cause of cancer death for both men and women. And there are 53,000 estimated colorectal cancer deaths in 2020. The age-adjusted incidence of colorectal cancer screening colorectal cancer has decreased by 31% from 1995 to 2015. And there is a thought that a lot of this is attributable to screening. However, recent epidemiologic data shows incidence of colorectal cancer is increasing among younger birth cohorts. We screen for colorectal cancer because it's a leading cause of cancer death and usually develops over a period of several years without symptoms. There are several screening methods that accurately detect early stage disease and early interventions are effective for reducing death from colon cancer. To inform our new recommendation, we commissioned a systematic review that looked at the benefits and harms of screening for colorectal cancer in adults from 40 years and older. We have a comparative effectiveness of screening strategies that was part of this review. And we also looked at whether findings varied by age, sex, race, or ethnicity. This recommendation also required a CISNA model so that we could understand in greater detail life years gained from screening, colorectal cancer cases and deaths subverted, lifetime number of tests, and complications attributable to different screening strategies, along with determining the best starting and stopping ages for screening. So this is what our new recommendation looks like. For adults age 50 to 75, we continue to recommend screening for colorectal cancer, and that's a grade eight recommendation. The new part of this recommendation is that for adults between 45 and 49, we recommend screening for colon cancer. And this is a B grade recommendation. And for adults age 76 to 85, we recommend that clinicians selectively offer screening for colorectal cancer in this group, and tailor it to the patient's desires with regard to screening and the individualized risk. So when we compare this to our 2016 recommendation, the big difference is that we now have a B level recommendation for people age 45 to 49. In terms of the accuracy of screening, all of the accuracy studies use colonoscopy as the reference standard. And all of the screening tests have lower sensitivity for detecting advanced adenomas. But when we look at the specific tests, the SDNA FIT results have more false positives than the FIT testing alone. The accuracy of the highly sensitive fecal occult blood test is less certain, but it's likely to be lower than the other stool-based tests based on earlier data collected with the fecal occult blood test. The CT colonography has reasonable accuracy to detect CRC and adenomas. And 12 studies examined age differences, but no difference in accuracy of tests for people between 40 and 49. So when we think about benefit, the USPSTF is not recommending one specific test, but rather, we continue to recommend a number of tests to choose from, some that are stool-based and some that are direct imaging. So the direct evidence that screening reduces cancer mortality for colon cancer. In colonoscopy, we have two prospective cohort studies together with a very large sample size that show an adjusted hazard ratio of 0.32 and a standardized risk of 0.42 after eight to 24 years of observation. So this is a very strong result. Flexible sigmoidoscopy, there are four randomized trials, and there also is reduced mortality from colorectal cancer in this group with a relative risk of 0.74 after 11 to 17 years of follow-up. For the fifth study, there is one large Taiwanese prospective study with over 5 million people in it. And here we see a relative risk of 0.9 for reducing colon cancer mortality after six years of observation. And for the fecal occult blood test, there are multiple older randomized trials that also show a significant reduction in colon cancer mortality. Some of these studies included people younger than 50, but none reported out on that age group separately. This is a summary of the harms. So when we think about the stool-based tests, the harms attributable to those tests are due to false positives and false negative results and the harms associated with the follow-up direct imaging studies. For colonoscopy, serious harms include bleeding and perforations. And for flexible sigmoidoscopy, we have a lower rate of serious bleeding and perforations compared to colonoscopy. For CT colonography, radiation is a risk and extracolonic findings. In this figure that you have here, the red dots are the serious bleeding rates and the open circles are for perforations. I'm going to go to have you focus on the bottom half of this slide, where we look at the benefit of colorectal cancer cases averted per thousand individuals screened. To orient you to the histograms, the light blue bars are the benefits that would be accrued if we started screening at age 50. The dark blue extensions are the added benefits if you start at age 45. The tests here in the column on the left edge are ordered by the stool tests first and the direct visualization tests second. And so what you see is that starting at age 45 does accrue more benefit in terms of cases averted. The histogram on top is a similar figure, but it looks at life years gained per thousand people screened. We can also look at deaths averted, and that's what the top histogram is here. And so you can see on the margin how many more deaths are averted by starting at the younger age of 45 versus 50 based on the modeling studies. And then finally on the bottom of this slide are the harms. And so we can see that the big takeaway message from the bottom is that by starting at age 45, we're not accruing a lot more harms than if we start at age 50 for the stool-based tests or even for the direct visualization tests. And part of that is because the complications of bleeding and perforation tend to happen more in older adults. So this is a summary that estimates the harms and benefits of different screening strategies. And so the complications or the harms are the green bars going toward the left, and the benefits are the blue bars going towards the right. And this is in life years gained per thousand people screened on the blue or benefit side. And then it is complications per thousand people screened on the harm side. And so taking these data in the aggregate, we felt like the benefits far outweighed the harms of reducing the screening onset age to 45. So what about black adults? Well, we know that black adults have the highest incidence of and mortality from colorectal cancer screening compared to other racial and ethnic groups. We also know that the most likely causes of this are inequities in implementation of screening and subsequent care due to systemic racism. But the recent increase in colorectal cancer among young adults has not been observed in black adults. It is mainly been seen in whites and Latinx persons. That said, there's very little evidence of benefits or harms that are race stratified in the literature. So this is just summarizing our recommendation again about our assessment of the net magnitude of benefit and how it informs these categories. And I've read this already, so I'll leave it up to you to read. And then in terms of screening strategies, we don't have a dominant strategy. So we recommend the stool-based strategies at the intervals that you see here on the slide. And then we recommend the direct visualization tests. And this really comes down to patient preference and provider and patient decision-making in terms of which tests get selected. Considerations at this point, all adults age 45 to 75 should be offered screening. The risks and benefits vary somewhat by the screening strategy. We recognize that there's a higher colorectal cancer incidence and mortality in black adults. And we're strongly encouraging clinicians to ensure that their black patients receive recommended colorectal cancer screening, appropriate follow-up and treatments. The development of systems of care to ensure that adults receive high quality care across the continuum of screening and treatment with special attention in black communities who have worse health outcomes from this condition is critically needed. And for adults 76 to 85, you really have to balance the harms and benefits because they become less favorable, but there may be selected individuals with excellent health status who still should consider possibly being screened. I'm going to stop there and turn the floor over to my colleague, Tina Phan. Thank you. Thank you, Dr. Mangione. So I'm going to be finishing up today's session by giving you a brief update on some of the methods work the task force has been doing on how it makes recommendations for diverse populations. First, I'm going to talk about some of the foundational work the task force laid out on how it makes recommendations for diverse populations. Then I'll share a bit about how the task force has evolved in its thinking around this area and highlight a recent viewpoint it published in JAMA earlier this year on how it plans to address systemic racism through its recommendations. Lastly, I'll share some recent examples of how the task force is starting to put this into practice in which Dr. Mangione just gave you a preview of. So the task force's 2017 paper on developing recommendations for diverse populations described what type of evidence they would need to be able to develop a different recommendation for specific populations and the processes the task force has put in place to gather that information. Underlying this work was the task force's recognition that specific segments of the US population may differ from the general population in terms of disease patterns or effectiveness of preventive services. Specific populations may be identified by demographic characteristics such as age, race, ethnicity, or sex, or by other factors such as biology, behavior, or heredity. In the 2017 paper, the task force outlined how it would consider diverse populations in each of the steps of its recommendation development process. Starting with the very first step, which is crafting the research plan, the task force identifies which populations may be disproportionately affected by a condition and how to scope the review to ensure that they are able to evaluate the available evidence on preventive services in these specific populations. Next, the task force wants to make sure its systematic review process proactively abstracts, analyzes, and synthesizes the available literature with respect to diverse populations. The task force does this by interacting closely with the review team who will be performing the evidence review for the task force. The task force asks the review team to look for data on disease burden in specific populations. And when reported in the task force, and when reported in studies, to make sure to abstract data on participant characteristics and stratified results. They also ask the review team to perform additional stratified or sensitivity analyses as appropriate. Once the task force reviews the evidence, it then tries to determine whether there's enough evidence to support creating a different recommendation for a specific population that could improve the health of that specific population over including them in the recommendation for the general population. To issue a separate recommendation grade, the task force must find adequate evidence that there would be a difference in the magnitude of net benefit in performing a preventive service for the specific population compared to the general population. So for example, would lowering the screening age only in black adults provide a different net benefit than lowering the screening age for all adults? To make that determination, the task force looks at the volume and quality of evidence, whether there's evidence beyond epidemiology, such as empiric evidence, and is there direct evidence available in a specific population, or does the task force have to apply evidence from one population onto another and extrapolate potential benefits or harms? If the task force has to use extrapolation, then it needs to consider whether the task force's overall certainty of the evidence needs to change. When evidence is insufficient, the task force calls for more research to address this evidence gap. A more recent article the task force published as a viewpoint in JAMA earlier this year reflects an evolution of that earlier work. It takes the task force one step further in ensuring its recommendations improve the health of diverse populations across the country by addressing systemic racism in their recommendations. The task force pledges to advance its methods to better identify when systematic racism contributes to health inequities and to include evidence-based strategies that will reverse negative effects of systemic racism in preventable disease. The task force commits to six action items in this viewpoint. The first is to consider race primarily as a social and not a biological construct. Secondly, the task force is promoting diversity within its own membership and leadership. The task force is also committing to commission a review on how systemic racism undermines the benefits of clinical preventive services. The task force is also planning to update its methodology to integrate the best evidence and consistently address evidence gaps for black, indigenous, and Hispanic Latino populations. The task force uses a consistent and transparent approach to communicate evidence gaps related to systemic racism and in preventive care, and it is pledging to address this both in their task force recommendation statements as well as in its annual report to Congress. Lastly, the task force is committed to collaborating with others to reduce the influence of systemic racism on health. In a supplementary table, the task force provides a roadmap of how it proposes to address each of these action items. We don't have time to go over all of these in detail, but I did want to highlight an underlying theme to all of these. The task force wants to go beyond recognizing health disparities and health inequities and wants to take concrete steps to better understand the causes of these disparities, including addressing systemic racism, and to identify evidence-based ways to reduce these health disparities and inequities. Moving forward, the task force plans to identify frameworks and strategies to eliminate health inequities through clinical preventive services, to include methods to identify the contribution of systemic racism and health inequities, to identify outcomes needed to measure and address health, to address racism, and also to identify how to communicate evidence gaps in health disparities in a way to actually get these gaps filled. So, the last part of my part of the presentation is to go over two examples of how the task force has really started putting this work into practice. And so, as you heard from Dr. Mangione, a lot of this work was highlighted on the task force's recommendations for lung cancer screening and for colorectal cancer screening. In the lung cancer screening recommendation, the task force recognized that lung cancer incidence is higher in Black men. In addition to smoking exposure, it also found differences may be related to other factors. The task force found data suggesting that Black adults who smoke may have a greater risk of lung cancer at lower levels of smoking intensity compared to White adults. Reviewing findings from the Southern Community Cohort Study, they also found that based on the task force's previous 2013 lung cancer screening recommendations, fewer Black adults were eligible for screening than White adults. Looking at the modeling analyses that the task force commissioned this time around for the update, the task force found that lowering the age to start screening, as well as pack your smoking history, would increase the relative percentage of Black adults and Hispanic adults eligible for screening greater than White adults. As you heard, this contributed to the task force's current recommendation to start lung cancer screening at an earlier age, age 50 rather than 55, and at a lower pack your smoking history, 20 pack years instead of 30 pack years. Turning to colorectal cancer screening, which as you heard was just finalized today, so go check out the task force website and take a look at it. For this topic, recognizing that Black adults have the highest incidence of mortality from colorectal cancer compared to other race and ethnicities, the task force specifically looked for evidence on how to improve colorectal cancer outcomes in Black adults. It looked for both empiric evidence and modeling analysis. It commissioned modeling work from CISNET to see if benefits and harms of screening would be different for Black adults compared to White adults. But when CISNET did its background literature search to find out how to quantify this increased risk of colorectal cancer in Black adults, they found evidence suggesting that this increased incidence of colorectal cancer was likely due to inequities in the access, utilization, and quality of colorectal cancer screening and treatment rather than genetic differences. And so they could not model an increased biologic risk. Subsequently, the task force was not able to identify enough evidence to call out a separate recommendation for colorectal cancer screening in Black adults. Instead, it dedicated a specific section of its practice considerations, part of the recommendation, to address the self-disparity and describe the disease burden and available evidence as well as how to advise Black adults on colorectal cancer screening. So this last slide just gives you the references of the articles I spoke about today as well as one more that the task force has put out that we didn't have time to review today on social determinants of health. And all of this information is available on the task force website. I think it's not letting me move forward, but I think now we're at our question and answer period. Thank you so much to all three of our wonderful speakers and the great presentation that you have provided us. I especially appreciated the update on addressing systemic racism. That's a really important topic and one that the college is hoping to address. So I don't see any questions coming up right now, but I'm wondering something that I have my residents do is comment on a recommendation when it's made, when you have it open for public comments. So I was wondering, what do you do with those comments and how does it make a difference in the recommendation? Sorry, Carol, did you want me to take that one? Please do. Okay. So all of the public comments are reviewed by the task force and they do consider them very carefully and they do really help improve the final recommendations. They often help indicate some area of the recommendation statement that needs to be clarified. But they are reviewed by the task force each and every comment and they are considered before the recommendation statement is finalized. Wonderful. Thank you so much. I think this will help my residents do an even better job knowing that each and every comment is going to be read and taken into consideration. If someone wanted to volunteer on the task force, what is the process for that? Do you want to take that or would you like me to? Carol, I'm happy to join in. So on our website, there's a nomination form and people can self-nominate or if they know other individuals who they feel would be qualified to be on the task force, they can nominate other people. The important thing about the task force, and I'm sure Dr. Wolf went over this, but we are 16 volunteers. We're all primary care providers with special training and research methods. And so I think some of the people sometimes who volunteer might not meet those categories exactly. They might not be primary care providers. But the nominations are then reviewed by our medical officers and our staff under Dr. Wolf's direction and we have a collaborative process for identifying the strongest candidates and then they are appointed by the director of AHRQ. Anything to add, Dr. Wolf or Dr. Pham? That's perfect. Anyone, as you mentioned, can nominate anyone at any time. The form is open all the time. We generally announce towards the end of the year or the beginning of the year for people to nominate and then generally have a deadline in the springtime so that we can consider all the nominations and appoint new members by the January 1 of the next year. Great. And one more question is we have the recommendation for e-cigarettes. I was really surprised that it was an I because given before COVID, the outbreaks of lung diseases that occurred because of e-cigarettes. So I was wondering if you could talk a little bit more about the e-cigarette and why it's an I. Sure. The important thing when you look at that recommendation, and I went by it really fast because there were a number of recommendations we were trying to present. The recommendation says it's an I or insufficient evidence for use of e-cigarettes to help with smoking cessation. So we're really not saying anything about the benefits or harms of picking up an e-cigarette habit. It's really about a recommendation for helping people quit smoking. And we could not recommend a strategy based on the clinical trials that have been done with e-cigarettes and the other evidence to help people quit smoking. The evidence was inadequate to balance the benefits and the harms of e-cigarettes for that purpose. So that's why it's an I. Great. Thank you so much for clarifying that. And if there are any other questions from the audience, please go to that little chart icon at the top and go ahead and type in a question. And are there any other final comments from the presenters? If we don't have any questions, we'll end the minutes early. I just want to thank you for this opportunity. Obviously, this is an incredibly important group of people in terms of not only being knowledgeable about prevention, but also disseminating information to providers. And so it's been really a privilege to have a chance to talk to you today. So thank you very much for the invitation. And I'm happy to take a few moments to share about all of the resources on the Task Force's website if we have a minute. Please do. I flashed up the Task Force's website, which is USPreventiveServicesTaskForce.org. Everything's on the website. So all of the systematic evidence reviews the Task Force uses are on there. The Task Force's draft recommendation statements, their finals. There are a wealth of a number of methods papers that describe how the Task Force makes recommendations. There's also many resources for professionals, clinicians, to use in implementing the Task Force's recommendations. So there's some decision tools. There's one about HIV PrEP, which is really great. There's also the opportunity to sign up for notifications. So whenever the Task Force posts something for comment or as final, you can sign up for notifications so you get an email for when that happens. There's also an app, too, that you can use in the clinical office as well. And one last plug. The Task Force is now on LinkedIn as well. So you can go to LinkedIn and sign up for Task Force posts that way as well. And less than two and a half hours ago in my clinic, I used the app. So I'm a big saleswoman of the app, and I really do try to get my residents using it. It's a very useful tool. Yes, I agree. I teach the app to the medical students here at Loma Linda University as well as my residents, so everyone is very familiar with that. We ask them to use it for different assignments. So I just wanted to thank you on behalf of the college for your presentation and for your update and for all of the work that you do with USPSDF. We really appreciate it, and thank you so much for taking the time to talk to us today. You're welcome. Thank you. Have a great day. Thank you. Enjoy the rest of the conference. If you have any questions or comments, please feel free to chat with me. My name is Karen Studer. I'm the track chair for the Clinical Preventive Medicine and Lifestyle Medicine track. Thanks so much for joining us. Thank you.

US Preventive Services Task Force

clinical preventive services

lung cancer screening

colorectal cancer screening

low-dose CT scans

smoking history

diverse populations

health disparities

systemic racism

health equity

accessing resources