Question

Difficulty: HardPreventive Care and Screening

A 71-year-old man presents to the clinic to establish care. He recently moved to the area to live closer to his family and has not seen a physician in six years. His medical history includes osteoarthritis of the knees and mild essential hypertension, both well-controlled with over-the-counter ibuprofen and lisinopril. He smoked 1.5 packs of cigarettes daily from age 20 to 50 but quit 21 years ago. He drinks one glass of wine on weekends. His previous medical records indicate that his last colonoscopy was performed at age 59 and revealed no polyps. A hepatitis C antibody test performed six years ago was negative. His most recent lipid panel and hemoglobin A1c, obtained during a community health fair last month, were within normal limits. His father died of a stroke at age 80, and his older brother was treated for localized prostate cancer at age 68. The patient is asymptomatic and his physical examination is unremarkable. Which of the following is the most appropriate combination of screening tests to recommend for this patient?

  1. Colonoscopy and abdominal ultrasonographyAnswer
  2. B
    Colonoscopy, abdominal ultrasonography, and low-dose chest computed tomography
  3. C
    Colonoscopy, abdominal ultrasonography, and prostate-specific antigen testing
  4. D
    Colonoscopy and low-dose chest computed tomography
  5. E
    Abdominal ultrasonography and prostate-specific antigen testing

Answer

The correct combination of screening tests is a colonoscopy and an abdominal ultrasonography.
The correct combination includes a colonoscopy and an abdominal ultrasonography. Colorectal cancer screening is a Grade A recommendation for all adults aged 45 to 75; this patient is 71 and his last colonoscopy was 12 years ago, making him currently due for screening. Additionally, a one-time abdominal ultrasonography is a Grade B recommendation to screen for an abdominal aortic aneurysm in men aged 65 to 75 who have ever smoked. Since he has never had this ultrasound, it is strongly indicated at this visit.

Step-by-Step Solution

1
Analyze the patient's demographics, past screening history, and risk factors.
The patient is a 71-year-old male. He had his last colonoscopy 12 years ago. He has a 45 pack-year smoking history but quit 21 years ago. He has a family history of prostate cancer.
Identifying precise age, timeline of past screenings, and duration since quitting smoking is critical for applying USPSTF age and time-based cutoffs.
2
Evaluate the indication for colorectal cancer screening.
Colorectal cancer screening is indicated.
USPSTF recommends screening for all adults aged 45 to 75. Since his last normal colonoscopy was 12 years ago, he has surpassed the 10-year interval and is currently due.
3
Evaluate the indication for abdominal aortic aneurysm (AAA) screening.
A one-time abdominal ultrasonography is indicated.
USPSTF recommends a one-time screening for AAA in men aged 65 to 75 who have ever smoked. He has never had this screening.
4
Evaluate the indication for lung cancer screening.
Low-dose chest computed tomography (LDCT) is not indicated.
Although he is within the age range (50-80) and meets the pack-year criteria (>20 pack-years), screening is discontinued once a person has not smoked for 15 years. He quit 21 years ago.
5
Evaluate the indication for prostate cancer screening.
Prostate-specific antigen (PSA) testing is not indicated.
The USPSTF recommends against PSA-based screening for prostate cancer in men aged 70 and older (Grade D), as the potential harms outweigh the benefits, even with a family history.

Key Concept

Application of USPSTF preventive screening guidelines for older adults, specifically recognizing upper age limits and time-since-quitting cutoffs for lung, colon, prostate, and abdominal aortic aneurysm screening.
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