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Difficulty: Very hardPreventive Care and Screening

An outpatient physician is reviewing the electronic medical record of a 62-year-old female patient prior to her scheduled annual wellness visit this afternoon. The patient has a history of HIV, initially diagnosed 15 years ago, which remains well controlled on a daily regimen of bictegravir, emtricitabine, and tenofovir alafenamide. Her most recent CD4 cell count is 620 cells/mm³ with an undetectable viral load. Additional medical history includes hypertension and hyperlipidemia.

The patient is a former smoker who accumulated a 40 pack-year smoking history before quitting 12 years ago. Her family history is notable for a mother who was diagnosed with colon cancer at age 78.

A comprehensive review of her recent cancer screening history reveals the following:
- Low-dose chest computed tomography (LDCT): normal at age 61
- Screening mammography: normal at age 61
- Dual-energy x-ray absorptiometry (DEXA): T-score of -1.2 at the femoral neck at age 61
- Cervical cytology with HPV co-testing: negative for intraepithelial lesion and malignancy, negative for high-risk HPV at age 59
- Screening colonoscopy: no polyps identified at age 54

Based on current guidelines, which of the following cancer screening interventions should the physician recommend during today's visit?

  1. A
    Low-dose chest computed tomography only
  2. B
    Cervical cytology with HPV co-testing, low-dose chest computed tomography, and screening colonoscopy
  3. C
    Screening mammography and low-dose chest computed tomography
  4. Cervical cytology with HPV co-testing and low-dose chest computed tomographyAnswer
  5. E
    Reassurance that she is currently up to date with all age- and risk-appropriate cancer screenings

Answer

The correct answer is to recommend cervical cytology with HPV co-testing and low-dose chest computed tomography.
This patient requires two specific cancer screening tests today based on her risk profile. First, she requires annual lung cancer screening with low-dose chest computed tomography (LDCT) because she is between 50 and 80 years old, has a ≥20 pack-year smoking history, and quit within the past 15 years (quit 12 years ago). Since her last LDCT was 1 year ago, she is due today. Second, she requires cervical cancer screening. Although average-risk women over age 30 can undergo cervical co-testing every 5 years, women living with HIV must undergo co-testing every 3 years due to their immunocompromised state. Her last co-test was at age 59, making her due at age 62.

Step-by-Step Solution

1
Evaluate lung cancer screening requirement.
Patient has a 40 pack-year history and quit 12 years ago. She requires LDCT today.
USPSTF requires annual LDCT for adults aged 50-80 with ≥20 pack-years who currently smoke or quit within the past 15 years. Her last LDCT was 1 year ago, so she is due for her annual screening.
2
Evaluate cervical cancer screening requirement.
Patient is HIV-positive and her last co-test was 3 years ago. She requires co-testing today.
While average-risk women aged >30 undergo co-testing every 5 years, immunocompromised women living with HIV must undergo co-testing every 3 years. Her last test at age 59 means she is due at age 62.
3
Evaluate colon cancer screening requirement.
Patient has a mother diagnosed with colon cancer at age 78. She does not require a colonoscopy today.
A first-degree relative diagnosed with colorectal cancer at ≥60 years keeps the patient at an average-risk 10-year screening interval. Her last colonoscopy at age 54 means the next is due at age 64.
4
Evaluate breast cancer screening requirement.
Patient had a normal mammogram 1 year ago. She does not require mammography today.
The USPSTF recommends biennial (every 2 years) mammography. Since her last was at age 61, the next is due at age 63.

Key Concept

Preventive cancer screening intervals often differ for immunocompromised populations (e.g., 3-year cervical co-testing for HIV) and require careful tracking of annual requirements (e.g., LDCT for heavy smokers).
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Topics

Preventive Care and Screening

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