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Difficulty: HardPreventive Care and Screening

An established 62-year-old female patient presents for an annual health maintenance visit. Her active medical problems include Crohn disease (currently maintained on infliximab) and type 2 diabetes mellitus. She smoked one pack of cigarettes daily from age 20 to 50 but quit 12 years ago (30 pack-year history). Her mother was diagnosed with breast cancer at age 70.

Her preventive care history includes the following:
- Screening mammography 11 months ago, which was interpreted as normal
- Total abdominal hysterectomy with bilateral salpingo-oophorectomy at age 45 for symptomatic uterine fibroids
- Colonoscopy 4 years ago, which revealed a single 6-mm tubular adenoma

Her immunizations for influenza, COVID-19, and tetanus-diphtheria-acellular pertussis (Tdap) are up to date. She has never received a zoster vaccine.

Which of the following preventive interventions are indicated for this patient during today's visit? (Select all that apply)

  1. Annual low-dose computed tomography (LDCT) of the chestAnswer
  2. Recombinant zoster vaccineAnswer
  3. C
    Screening mammography
  4. D
    Vaginal vault cytology
  5. E
    Fecal immunochemical test (FIT)

Answer

The correct interventions are annual low-dose computed tomography (LDCT) of the chest and the recombinant zoster vaccine.
The patient meets current criteria for lung cancer screening with annual low-dose computed tomography (LDCT), as she falls within the 50 to 80 age range, has a ≥20\geq 20 pack-year smoking history, and quit within the last 15 years. The recombinant zoster vaccine is also indicated, as it is recommended for all adults aged 50 and older, regardless of prior herpes zoster episodes. Furthermore, her use of infliximab represents an immunocompromising condition, making the non-live recombinant zoster vaccine highly indicated and safe to administer.

Step-by-Step Solution

1
Evaluate criteria for lung cancer screening.
LDCT is indicated.
The patient is between 50 and 80 years of age, has a 30 pack-year smoking history, and quit within the last 15 years (quit 12 years ago).
2
Evaluate immunization requirements based on age and comorbidities.
Recombinant zoster vaccine is indicated.
She is over 50 years old and has never received it. Additionally, her use of infliximab (a TNF inhibitor) makes her immunosuppressed, independently qualifying her for the recombinant (non-live) zoster vaccine.
3
Analyze intervals for breast, cervical, and colorectal cancer screenings.
None of these are currently indicated.
Breast cancer screening is biennial (hers was 11 months ago). Cervical screening is discontinued after benign hysterectomy. Colorectal surveillance for a single low-risk adenoma is at 7-10 years, with no interval FIT testing.

Key Concept

Application of multiple concurrent, evidence-based preventive screening guidelines and immunization schedules in an adult with specific risk factors and complex medical history.
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Topics

Preventive Care and Screening

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