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Difficulty: HardPreventive Care and Screening

A 68-year-old woman comes to the clinic for an annual health maintenance examination. She has a history of primary hypertension and osteoarthritis. She underwent a total abdominal hysterectomy and bilateral salpingo-oophorectomy at age 48 for symptomatic uterine fibroids. Pathological examination of the uterus and cervix at that time was benign, and her prior cervical cancer screening tests were consistently normal. She recently became sexually active with a new male partner.

Her most recent colonoscopy was performed at age 62 and revealed no polyps or abnormalities. She underwent a screening mammogram and a dual-energy x-ray absorptiometry (DXA) scan three months ago, both of which were within normal limits. She has a 40-pack-year history of smoking but successfully quit 10 years ago. She currently takes lisinopril and acetaminophen as needed. Vital signs are within normal limits.

Which of the following is the most appropriate next step in screening for this patient?

  1. Low-dose computed tomography of the chestAnswer
  2. B
    Papanicolaou test of the vaginal vault
  3. C
    Fecal immunochemical testing
  4. D
    Ultrasonography of the abdominal aorta
  5. E
    Transvaginal ultrasonography and serum CA-125

Answer

The most appropriate next step in screening is low-dose computed tomography of the chest.
The US Preventive Services Task Force (USPSTF) recommends annual screening for lung cancer with low-dose computed tomography (LDCT) in adults aged 50 to 80 years who have a 20 pack-year or greater smoking history and who currently smoke or have quit within the past 15 years (Grade B recommendation). This patient is 68 years old, has a 40 pack-year smoking history, and quit 10 years ago. Therefore, she precisely meets the criteria for annual LDCT screening.

Step-by-Step Solution

1
Analyze the patient's demographics, smoking history, and surgical history.
The patient is a 68-year-old female with a 40 pack-year smoking history who quit 10 years ago. She had a total hysterectomy for benign disease and a normal colonoscopy 6 years ago.
Identifying specific clinical parameters and timelines is essential to applying age- and risk-based screening guidelines accurately.
2
Evaluate the indication for lung cancer screening.
The patient meets all criteria for annual low-dose computed tomography (LDCT).
USPSTF guidelines strongly recommend (Grade B) annual LDCT for adults aged 50-80 with a 20 pack-year or greater smoking history who currently smoke or have quit within the last 15 years.
3
Rule out competing screening modalities based on guidelines and patient history.
Pap testing is contraindicated post-total hysterectomy; FIT is unnecessary within the 10-year colonoscopy interval; AAA screening is Grade I for women; and ovarian screening is Grade D.
Eliminating distractors ensures that the single, strongly evidence-based (Grade A or B) screening intervention is selected.

Key Concept

Application of age- and risk-stratified USPSTF preventive screening guidelines in primary care, specifically differentiating indications based on surgical history, gender, and smoking status.
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Topics

Preventive Care and Screening

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