1. USPSTF Screening Recommendations: Implications for Adults at Higher Risk NYFAHC Roundtable, June 18, 2013 Robert A. Smith, PhD Senior Director, Cancer Control Science Cancer Control Sciences Department

2. Cancer Screening, the ACA, and the USPSTF Under the ACA, preventive services that are given an A or B rating by the USPSTF must be provided without any co-pays or deductibles USPSTF screening recommendations specifically are targeted to average risk adults

3. Cancer Screening, the ACA, and the USPSTF The need for a different screening regimen for adults at higher risk typically is acknowledged, but recommendations are not issued due to lack of adequate evidence The USPSTF commonly acknowledges that other organizations have issued different and specific recommendations for adults at higher risk

4. Colorectal Cancer Screening

5. Colorectal Screening in Average Risk Adults: Update 2008 RecommendationACS, USMSTF, ACRUSPSTF Age to begin and end screening Begin screening at age 50 End screening at a point where curative therapy would not be offered due to life- limiting co-morbidity Begin screening at age 50 Routine screening in adults aged 76-85 is not recommended. There may be considerations that support screening in an individual patient. Screening after age 85 is not recommended

6. CRC Screening in Average Risk Adults: Update 2008 RecommendationACS, USMSTF, ACRUSPSTF CRC screening between ages 76-85 Adults in good health who would be candidates for treatment should continue screening Recommend against routine screening in adults 76-85. There may be considerations that support screening in an individual patient. CRC screening in adults over age 85 Screening not recommended in adults > 85 years

7. USPSTF Clinical Considerations “These recommendations apply to adults 50 years of age and older, excluding those with specific inherited syndromes (the Lynch syndrome or familial adenomatous polyposis) and those with inflammatory bowel disease. The recommendations do apply to those with first-degree relatives who have had colorectal adenomas or cancer, although for those with first-degree relatives who developed cancer at a younger age or those with multiple affected first- degree relatives, an earlier start to screening may be reasonable.”

8. USPSTF Clinical Considerations “When the screening test results in the diagnosis of clinically significant colorectal adenomas or cancer, the patient will be followed by a surveillance regimen and recommendations for screening are no longer applicable. The USPSTF did not address evidence for the effectiveness of any particular surveillance regimen after diagnosis and/or removal of adenomatous polyps.”

9. INCREASED RISK HIGHEST RISK AVERAGE RISK

10. Breast Cancer Screening Guidelines

11. Breast Cancer Screening in Average Risk Women: ACS (2003); USPSTF (2009) RecommendationACSUSPSTF MammographyAge 40+ - Annual Screening The USPSTF recommends biennial screening mammography for women between the ages of 50 and 74 years. (Grade B recommendation)

12. Breast Cancer Screening in Average Risk Women: ACS (2003); USPSTF (2009) RecommendationACSUSPSTF MammographyEnd screening at a point where curative therapy would not be offered due to life- limiting co-morbidity The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older. (I statement)

13. Breast Cancer Screening in Average Risk Women: ACS (2003); USPSTF (2009) RecommendationACSUSPSTF Age to begin and end screening Begin screening at age 50 End screening at a point where curative therapy would not be offered due to life- limiting co-morbidity Begin screening at age 50 Routine screening in adults aged 76-85 is not recommended. There may be considerations that support screening in an individual patient. Screening after age 85 is not recommended

14. USPSTF Clinical Considerations “This recommendation statement applies to women 40 years or older who are not at increased risk for breast cancer by virtue of a known underlying genetic mutation or a history of chest radiation.”

15. ACS Guidelines for Breast MR in High Risk Women

16. Cervical, Prostate, and Lung Screening ACS and USPSTF cervical cancer screening guidelines are similar USPSTF recommends against prostate cancer screening. ACS recommendations accommodate men at average and high risk Lung cancer screening recommendations are expected in 2013

17. Thank you