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Difficulty: MediumPreventive Care and Screening

A 56-year-old woman comes to the clinic for a routine wellness examination. She feels well and has no specific concerns today. Her past medical history is notable for hypertension, which is well controlled with lisinopril. She has never smoked cigarettes, consumes alcohol occasionally, and exercises three times a week. Her family history is negative for cancer or osteoporotic fractures.

A review of her electronic medical record reveals the following recent screening results:
- Screening mammography performed 12 months ago showed no evidence of malignancy (BI-RADS category 1).
- Fecal immunochemical test (FIT) performed 12 months ago was negative.
- Cervical cytology with high-risk human papillomavirus (hrHPV) co-testing performed 3 years ago was negative for intraepithelial lesion or malignancy and negative for hrHPV.
- Fasting lipid panel and hemoglobin A1c performed 6 months ago were within normal limits.

She is up to date on all recommended vaccinations. Her body mass index is 24 kg/m².

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

  1. A
    Dual-energy x-ray absorptiometry
  2. Fecal immunochemical testAnswer
  3. C
    Low-dose chest computed tomography
  4. D
    Repeat cervical cytology with hrHPV co-testing
  5. E
    Repeat screening mammography

Answer

The most appropriate next step is to perform a fecal immunochemical test (FIT).
The correct answer is to perform a fecal immunochemical test (FIT). For average-risk adults aged 45 to 75 years, the United States Preventive Services Task Force (USPSTF) recommends routine colorectal cancer screening. There are multiple acceptable screening modalities, but they operate on different required intervals. Acceptable strategies include an annual fecal immunochemical test (FIT), an annual high-sensitivity guaiac fecal occult blood test (hsgFOBT), a multitarget stool DNA test every 1 to 3 years, a flexible sigmoidoscopy every 5 years, or a colonoscopy every 10 years. Because this patient's last FIT was exactly 12 months ago, she is due for her annual repeat screening today to maintain adequate sensitivity for detecting occult malignancy.

Step-by-Step Solution

1
Evaluate the patient's baseline demographics and risk factors.
The patient is a 56-year-old female at average risk for most malignancies, with no smoking history and no significant family history of cancer.
Age, sex, and risk factors determine which United States Preventive Services Task Force (USPSTF) guidelines apply.
2
Assess colorectal cancer screening status.
Her last FIT was performed 12 months ago. USPSTF guidelines recommend colorectal cancer screening for adults aged 45 to 75. If FIT is the chosen modality, it must be performed annually.
To determine if repeat colorectal screening is indicated today.
3
Assess breast and cervical cancer screening status.
Her last mammogram was 12 months ago; USPSTF recommends biennial (every 2 years) screening, so she is not due. Her last cervical co-testing was 3 years ago; guidelines recommend every 5 years, so she is not due.
To rule out the need for other routine screenings.
4
Assess indications for osteoporosis and lung cancer screening.
She is under 65 with no fracture risk factors, so a DEXA scan is not indicated. She has never smoked, so low-dose chest CT is not indicated.
To avoid inappropriate overutilization of imaging modalities.

Key Concept

The recommended interval for colorectal cancer screening using the fecal immunochemical test (FIT) is annually. In contrast, standard-risk screening mammography is recommended biennially, and cervical cancer co-testing is recommended every 5 years.
Estimated Time:1m 15s
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Topics

Preventive Care and Screening

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