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Difficulty: Very hardPreventive Care and Screening

A 66-year-old woman comes to the office for a routine health maintenance evaluation. She has a past medical history of estrogen receptor-positive left breast cancer treated with a lumpectomy and radiation therapy at age 52. She subsequently completed a 5-year course of letrozole and has remained in remission. Her social history is notable for smoking one pack of cigarettes daily for 30 years, but she successfully quit 16 years ago.

Her most recent preventive care includes:
- A screening colonoscopy at age 56, which revealed no polyps.
- Mammography of both breasts 12 months ago, which showed post-surgical changes on the left and no evidence of malignancy (BI-RADS 2).
- Cervical cytology with high-risk human papillomavirus (hrHPV) co-testing at age 62, which was negative for both. She also had a negative co-test at age 57, and no history of high-grade precancerous cervical lesions.

She has no new physical complaints. Her body mass index is 25 kg/m².

Which of the following is the most appropriate set of cancer screening recommendations for this patient today?

  1. Order screening mammography and a colonoscopy; discontinue cervical cancer screeningAnswer
  2. B
    Order screening mammography, low-dose computed tomography (LDCT) of the chest, and a colonoscopy; discontinue cervical cancer screening
  3. C
    Order screening mammography, a colonoscopy, and cervical cytology with high-risk HPV co-testing
  4. D
    Order a colonoscopy and low-dose computed tomography (LDCT) of the chest; discontinue screening mammography and cervical cancer screening
  5. E
    Order screening mammography; discontinue cervical and colorectal cancer screenings

Answer

Screening mammography and a colonoscopy should be ordered, and cervical cancer screening should be discontinued.
The correct set of recommendations involves continuing breast and colorectal cancer screenings while discontinuing cervical and lung cancer screenings. This patient requires an annual mammogram due to her personal history of breast cancer treated with a lumpectomy. Her last mammogram was 12 months ago, making her due now. Colorectal cancer screening is recommended for average-risk adults up to age 75. Her last colonoscopy was 10 years ago and was normal, so she is due for repeat screening today. Cervical cancer screening can be safely discontinued because she is over age 65 and has had adequate prior screening (at least two consecutive negative hrHPV co-tests within the past 10 years, with the most recent occurring within the last 5 years). Finally, she does not qualify for lung cancer screening with low-dose computed tomography (LDCT) because, although she has a significant pack-year history, she quit 16 years ago. The USPSTF recommends discontinuing LDCT once a patient has not smoked for 15 years.

Step-by-Step Solution

1
Evaluate the need for ongoing breast cancer screening.
The patient requires an annual mammogram.
Patients with a personal history of breast cancer treated with breast-conserving surgery require annual surveillance mammography. Her last mammogram was 12 months ago.
2
Assess the indication for lung cancer screening with low-dose computed tomography (LDCT).
LDCT is not indicated.
Although the patient has a 30 pack-year history and is between 50 and 80 years old, she quit smoking 16 years ago. The USPSTF recommends discontinuing LDCT once a person has been smoke-free for 15 years.
3
Determine the status of cervical cancer screening.
Cervical cancer screening can be discontinued.
The patient is over age 65 and has had two consecutive negative hrHPV co-tests within the past 10 years, with the most recent within 5 years (at age 62). This meets the USPSTF criteria for screening cessation.
4
Determine the appropriate interval for colorectal cancer screening.
A screening colonoscopy should be scheduled.
The patient's last colonoscopy was 10 years ago at age 56. Average-risk individuals require repeat screening every 10 years until age 75.

Key Concept

Synthesis of age-based and history-based cancer screening cutoffs, specifically applying cessation criteria for lung and cervical cancers while maintaining ongoing surveillance for prior malignancies.
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Topics

Preventive Care and Screening

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