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Screening Tests for Adults
(50 and Older)

Screening tests are tools your health care provider uses for early detection of common and potentially deadly diseases, such as cancer, diabetes, and heart disease.

Breast Cancer

Breast cancer is the second leading cause of cancer death in American women. With timely mammograms for women 40 years of age and older, about 16 percent of all deaths from breast cancer could be prevented, say the nation’s public health advisors. This imaging test detects a lump an average of 1 to 3 years before you can feel it.

  • Middle-aged women: The American Cancer Society (ACS), American Medical Women’s Association, and numerous national women’s groups recommend annual screening for those of average risk as follows:
    • Beginning at 40 years of age, women should have a mammogram and breast exam by a health professional each year.
  • The U.S. Preventive Services Task Force supports a less rigorous approach:
    • Women 40 years of age or older should have a screening mammogram, with or without a breast exam by a health professional, every 1 to 2 years.
  • Older women: The ACS says older age is no reason to stop or be screened less often:
    • Mammograms for older women should be based on the individual, her health, and the effects of any serious illness (for example, congestive heart failure, end-stage renal disease, chronic obstructive pulmonary disease, or moderate-to-severe dementia). If you are in good health and your health enables you to be a candidate for treatment, continue getting mammograms.
These recommendations are for women without known risk factors for breast cancer. If you have an increased risk, discuss whether and when to use magnetic resonance imaging (MRI) as part of the screening strategy. The ACS link below provides a list of factors that can increase the risk of breast cancer, including genetic predisposition and family or personal history of breast cancer.

Cervical Cancer

  • The American Congress of Obstetricians and Gynecologists (ACOG) recommends that women 30 years of age or older be screened for the presence of human papilloma virus (HPV) with an HPV DNA test in addition to a Pap smear. Postmenopausal women should be tested for HPV only when the Pap smear is abnormal. Persistent infections with certain types (strains) of HPV are now known to be the major risk factor for cervical cancer. Two types of HPV, types 16 and 18, account for about 70% of cervical cancers in the U.S. Cigarette smoking and a compromised immune system have also been associated with the persistence of the HPV infection, which may progress to cancer.Women over 30 years old who have been sexually active, have no new risk factors, and have had 3 consecutive normal Pap tests should continue to be screened at least every 3 years with both tests, according to ACOG. Based on established guidelines and a joint decision between you and your physician, screening intervals may be lengthened for many women once they have had 2 or 3 normal Pap smears in a row.
  • The U.S. Preventive Services Task Force and American Cancer Society both released new guidelines in 2012 recommending that women between the ages of 21 and 65 be screened with a Pap test every 3 years; for women ages 30 to 65, having both a Pap smear and an HPV test every 5 years is preferable, although a Pap test alone every 3 years is also acceptable.
Over Age 65
ACOG further recommends discontinuing routine screening between the ages of 65 to 70 if three or more consecutive Pap smears are negative and  no other abnormalities have been identified within the last 10 years. Women who have had total hysterectomies for non-cancerous reasons and no other high-risk history could also discontinue routine screening.The USPSTF and ACS released new guidelines in 2012 recommending against screening for cervical cancer for women over the age of 65 who have had regular screening with normal results.

Colorectal Cancer

One third of colorectal cancer deaths could be prevented with regular screening, studies show. Because many people do not get screened, however, the disease is the third leading cause of cancer deaths in the United States. Cancer of the colon and rectum is both preventable and treatable if detected early.

Colorectal cancer can be prevented by looking for and removing polyps and lesions in the colon. Because these are found most often in people 50 years of age and older, experts recommend universal screening in this age group. Among the groups making this recommendation are the U.S. Centers for Disease Control and Prevention, the American Cancer Society, the American Academy of Family Physicians, and a multidisciplinary physician panel convened by the U.S. Agency for Healthcare Research and Quality (with the U.S. Multi-Society Task Force on Colorectal Cancer).

Adults 50 years of age and older who are of average risk should be routinely screened for colorectal cancer. Earlier, more frequent, and the most rigorous screening is appropriate at a younger age for those who have risk factors, often beginning at age 40.

For those of African descent, the American College of Gastroenterology recommends starting testing at a younger age: Americans of African descent should get screened starting at 45 years of age. The “first line” screening test for this group is a colonoscopy, which should be repeated every 10 years, suggests the gastroenterology group, unless additional risk factors, such as family history, warrant more frequent testing.

The recommendation reflects findings that Americans of African descent tend not only to be diagnosed with this cancer at a younger age than others but also to survive for a shorter period of time. Also, some evidence shows that those of African descent have more right-sided cancers and polyps (making the colonoscopy of greatest benefit).

When to stop screening

The U.S. Preventive Services Task Force (USPSTF) revised its guidelines in October 2008 to recommend against routine screening in people 76 to 85 years of age who have had consistently negative screenings since they were age 50 and against screening at all in those over the age of 85 years. This is in contrast to a 2003 study by the Cleveland Clinic Foundation, which concluded that colonoscopy screening is worthwhile into the eighth and ninth decades. Prior to the USPSTF’s revised guidelines, the common recommendation was for individuals to get tested periodically until their age or other illnesses limit their life expectancy.

Which test should you have?

Recommendations on colon cancer screening name seven acceptable tests. The tests are really of two types: lab tests analyzing your stool samples and procedures in which a specialist views images of the inside of your colon.

  • Lab tests find telltale blood or DNA – signs that cancer is present – in a stool sample. The three types of lab tests are the fecal occult blood test, the immunochemical fecal occult blood test, and the stool DNA test.
  • Imaging procedures show abnormalities – polyps and lesions – on the empty colon’s lining. Two of these use a scope with a video camera: colonoscopy views the entire length of the colon, and flexible sigmoidoscopy views the lower third. The other two use x-rays: virtual colonoscopy – a computed tomography (CT) scan – combines many cross-sectional images into 2-D and 3-D views of the colon, and a double-contrast barium enema (DCBE) provides x-ray views of lumps, polyps, and abnormalities in the outline of the colon.

In 2008, guidelines from the American Cancer Society, American College of Radiology, and U.S. Multi-Society Task Force on Colorectal Cancer urged getting a screening test good at finding both cancer and polyps, provided a procedure of this type is available to you and an invasive test is acceptable to you. They recommend relying more on the tests that can help prevent cancer rather than tests that only detect it. Their guidelines also broke ground in approving two more tests for screening: DNA analysis of the stool sample and virtual colonoscopy.

No single test is preferred for all individuals. Any one of the recommended approaches described below can be appropriate for a person of average risk, depending on the circumstances. The first four can find both polyps and cancer:

  • Flexible sigmoidoscopy every 5 years
  • Colonoscopy every 10 years
  • Double-contrast barium enema every 5 years
  • Virtual colonoscopy every 5 years

Particularly when the ease and safety of a sample-based test is desirable, one of the three lab tests can be used:

  • Fecal occult blood test (FOBT) or the simpler immunochemical fecal occult blood test (iFOBT or FIT) every year
  • Stool DNA test—optimal frequency not yet known; USPSTF found that not enough information was available yet for it to make a recommendation on use of this test.
  • Each test can be used alone, or two test types can be used in combination. When the findings are abnormal, a colonoscopy is needed.

Colonoscopy is the most accurate and thorough test but also the most costly and invasive; it is especially appropriate for those with risk factors. You may have reasons to choose a simpler test. Stool sample and sigmoidoscopy tests are easier but not as accurate; they are better used together and can be the best approach in specific situations. As the U.S. Centers for Disease Control and Prevention (CDC) notes, any of the recommended tests is better than no test.

Research is showing that attention needs to be paid not only to polyps but also to flat lesions on the colon’s lining. This may further influence the types of tests recommended. It also means the person viewing your images must work more carefully than ever.

Decision aids

Talk to your healthcare provider about the screening tests recommended for you. Some employers, health plans, and healthcare providers provide decision aids. Booklets, online tools, DVDs, and videos have been created on colon cancer screening tests.

Also, don’t neglect the protection of getting re-tested at the recommended interval. Ask or sign up for a mailed or e-mailed reminder (link below) or mark your calendar or date book.

Diabetes

Diabetes is the sixth leading cause of death in the United States, and your risk for this disease increases with age. About 21 percent of Americans 60 years of age or older have diabetes. One third of the 20 million Americans who have diabetes don’t even know it. Another 40 million have been tested and learned they have prediabetes. Recognizing prediabetes lets you take steps to stop or slow the development of type 2 diabetes, heart disease, and stroke. Diabetes leads to expensive complications and serious disabilities, including damage to the eyes, kidneys, nerves, and heart. Early detection of problems gives you the chance to make changes and take medicine that can help prevent type 2 diabetes from developing.

Many of the current guidelines advise a selective, rather than universal, approach to screening for diabetes mellitus. Note the wording in the recommendations of the National Institute for Diabetes and Digestive and Kidney Diseases (NIDDK). It emphasizes who should “consider” getting tested (who should discuss it with their healthcare provider) and for whom testing is “strongly recommended.”

  • Anyone 45 years of age or older should consider getting tested for diabetes.
  • If you are at least 45 years old and overweight, it is strongly recommended that you get tested by your healthcare provider.
  • If you are younger than 45, overweight, and have one or more risk factors (listed below), you should consider testing.

In addition, the U.S. Preventive Services Task Force (USPSTF) published updated recommendations in 2008 in favor of screening adults who have a blood pressure reading of greater than 135/80 mm Hg. The USPSTF, however, does not recommend screening of asymptomatic adults with blood pressure below that threshold due to the lack of evidence to assess the balance of benefits and harms.

A fasting plasma glucose (FPG) test or a 2-hour oral glucose tolerance test (OGTT) can be used to screen for diabetes. In addition to those tests, the American Diabetes Association (ADA) says that an A1c test may be a screening option for some people.  However, A1c should not be used for diabetes diagnosis in pregnant women, people who have had recent severe bleeding or blood transfusions, those with chronic kidney or liver disease and people with blood disorders such as iron-deficiency anemia, vitamin B12 anemia and hemoglobin variants. Also, only A1c tests that have been referenced to an accepted laboratory method (standardized) should be used for diagnostic or screening purposes. Currently, point-of-care tests, such as those that may be used at a doctor’s office or a patient’s bedside are too variable for use in diagnosis but can be used to monitor treatment (lifestyle and drug therapies).

The ADA suggests how often to repeat screening:

  • All adults 45 years of age and older should be considered for diabetes screening by their healthcare provider every 3 years, particularly those with a body mass index greater than 25 kg/m2. If you have prediabetes, have your blood glucose checked again in 1 to 2 years, advises the NIDDK.
  • In those who are overweight, testing should begin at an earlier age if additional risk factors are present and be repeated sooner.
Know your risk factors

The American College of Endocrinology and the American Association of Clinical Endocrinologists jointly recommend that you get tested for diabetes starting at 30 years old if you are in a high-risk group due to any of the following: Your family:

  • Your sister, brother, or parent has or had diabetes.
  • You are of Latino/Hispanic, African, Asian, Native American, Native Alaskan, or Pacific Island descent.

Your health:

  • You are overweight or have a sedentary lifestyle.
  • You have hypertension, cholesterol levels (triglycerides or high-density lipoproteins) of concern, heart or vascular disease, or a severe psychiatric illness.
  • Prior tests showed you had impaired glucose tolerance or impaired fasting glucose.

Women’s health issues:

  • You had gestational diabetes or gave birth to a baby larger than 9 pounds.
  • You have polycystic ovary syndrome.

High Cholesterol

Beginning in childhood, the waxy substance called cholesterol and other fatty substances known as lipids start to build up in the arteries. Slowly, over many years, these build-ups harden into plaques that narrow the passageway. During adulthood, plaque buildup and resulting health problems occur not only in arteries supplying blood to the heart muscle but in arteries throughout the body (a problem known as atherosclerosis). For both men and women in the United States, the number one cause of death is heart disease, and the amount of cholesterol in your blood greatly affects your chances of suffering from it.

Because heart disease is America’s biggest health problem, you can expect healthcare providers to be interested in helping you avoid its effects (a heart attack, stroke, serious disability, or even early death) by routinely ordering a blood cholesterol screening test. Having healthy cholesterol levels is important for men and women of all ages. The experts even encourage reducing unhealthy cholesterol intake in children and teens as a way to prevent heart disease in adulthood.

The National Cholesterol Education Program and the American Heart Association recommend the most rigorous screening approach, beginning in young adulthood:

  • Every 5 years, all adults 20 years of age and older should have a complete, fasting lipoprotein profile. If your lipid levels are low or repeatedly normal, you can go longer between tests. If your lipid levels are borderline, more frequent testing is advised.
  • If you fast for 9 to 12 hours before taking this blood test, the test provides four measurements: 1) total cholesterol, 2) LDL cholesterol, which you want to be low, 3) HDL cholesterol, which you want to be high, and 4) triglycerides, which are another form of fat in your blood. This fasting test is the preferred initial test, according to the National Cholesterol Education Program. Without fasting, two useful measurements can be obtained: total cholesterol and HDL cholesterol.

The U.S. Preventive Services Task Force, American Academy of Family Physicians, and American College of Preventive Medicine say you can start with the non-fasting test and, if you have no risk factors, begin monitoring your cholesterol later, in middle age. If these two measurements indicate a problem, you can have the more complete test done. Their recommendation:

  • All men 35 years of age and older and all women 45 years of age and older should be routinely screened for lipid disorders.
  • Younger adults – starting at 20 years of age – should be routinely screened for lipid disorders if they have other risk factors for coronary heart disease.
  • Problems with the heart and arteries surface most often in men over age 45 and women after age 55. The American Academy of Family Physicians warns women that, in later life, you are more likely to die of heart disease than from any cancer; your heart is less likely to survive a heart attack than a man’s.

You also are more vulnerable and would want more frequent testing if you have any known risk factors, such as smoking, high blood pressure (hypertension, 140/90 mm Hg or higher or you take antihypertensive medications), diabetes, overweight, a family history of early heart disease, a low level of the “good” HDL cholesterol (less than 40 mg/dL), or a high total and high LDL cholesterol. With just two risk factors, you fit into a category that benefits from closer monitoring.

On what age to stop, the U.S. Preventive Services Task Force says this: After age 65, you may not need to keep getting tested. Lipid levels are less likely to increase at this age; however, anyone over age 65 who has never been tested should have their cholesterol levels measured.

HIV

Universal testing for human immunodeficiency virus (HIV) has become routine healthcare in the United States. Many people do not realize that adults over 50 years of age make up 15 percent of new cases of HIV infection. Knowing your HIV status helps you protect your health. Learning you are infected helps you get treatment that can greatly improve your health and extend your life. Also, you learn what reduces the chance you will pass the virus on to others. If an HIV screening test shows you’re not infected, you can take steps to avoid infection. HIV is the virus that causes AIDS (acquired immunodeficiency syndrome), a deadly disease that is most often sexually transmitted. At least 90 to 95 percent of individuals who are infected with HIV will, within 3 months of exposure, develop enough antibodies to have a positive HIV test; over 99 percent of HIV-infected individuals will have a positive test within 6 months. If a pregnant woman is infected with HIV, the virus can be passed to and infect the fetus.

The U.S. Centers for Disease Control and Prevention (CDC) recommends screening for this infection as follows:

  • Everyone 13 to 64 years old should have an HIV screening test at least once.
  • Pregnant women should have at least one HIV test.
  • The CDC recommends getting tested each year if you’ve engaged in an activity that can spread an HIV infection.
Know your risk factors

Any of the following put you at risk and are a reason to have an HIV screening test soon, even if you have no symptoms of an infection, the U.S. Preventive Services Task Force and the American Academy of Family Physicians strongly suggest:

Sexual contacts of concern:

  • If you’ve had unprotected sex with 2 or more people
  • If you’re a male who, since 1975, has had sexual contact with another male
  • If you or a partner exchanged sex for money or drugs
  • If someone with whom you’ve had sex was HIV-infected, bisexual, or an injection drug user
  • If you’re being treated for a sexually transmitted disease (STD)

Other issues of concern:

  • If you use or used injection drugs (are likely to have shared unsterilized needles)
  • If between 1978 and 1985 you had a blood transfusion
  • How often you are tested should depend on your activities and sexual contacts. For example, during a long-term, truly monogamous sexual relationship, you may want just one test. However, if you or your partner have had sexual contact with more than one person in recent months, your risk of infection is greater. If you or a person with whom you’ve had sexual contact (even unwanted sexual contact) engaged in some risky behavior, you have even more reason to be tested.
Talk to your healthcare provider

Don’t be surprised if a healthcare provider, in any care setting, asks you or your partner to consent to an HIV screening test, in keeping with CDC recommendations. Routine HIV testing (which you can decline or “opt out” of) prevents feelings of embarrassment or shame from becoming obstacles to crucial healthcare. This universal, nonjudgmental approach protects those who hesitate or never get to discuss sexual health issues with a healthcare provider. Those infected find out sooner; they can then get treatment when it works best and take steps to protect the health of sex partners and even their unborn children.

Some healthcare providers may be more selective about screening for HIV and other STDs. Instead of routinely offering all patients such tests, they may, as time and circumstances allow, assess your risk and then decide whether to suggest a screening test or tests. Unfortunately, some may not discuss sexual health issues at all. This leaves the health risks unchecked. If your healthcare provider does not bring up sexual health topics, you can simply ask for a test or a risk assessment. You can also use confidential services to obtain testing or counseling.

Obesity

Two out of 3 adult Americans are overweight, and 1 out of 3 are obese. The rate of obesity has increased steadily throughout the U.S. in all age ranges, including children. For adults, the following definitions are used for classifying weight. They are based on the calculation of body mass index (BMI), which is defined as (weight in kg)x(weight in kg)/height in meters.

  • BMI < 18.5 Underweight
  • BMI 18.5-24.9 Normal
  • BMI 25.0 – 29.0 Overweight
  • BMI 30-39.9 Obese
  • BMI > 40 Morbidly obese

Obesity is a health concern because it increases the risk of many diseases such as high blood pressure (hypertension), dyslipidemias (high cholesterol and/or high triglycerides), Type 2 diabetes, coronary heart disease, stroke, gall bladder disease, osteoarthritis (degeneration of cartilage and underlying bone in a joint), sleep apnea and respiratory problems, and some cancers.

The U.S. Preventive Services Task Force recommends that healthcare providers screen all adult patients for obesity, and the American Academy of Family Physicians agrees. Measuring your BMI helps identify if you are at risk for a wide variety of serious health problems that may be avoided or delayed by lifestyle changes such as weight loss and exercise. The American College of Preventive Medicine advises this:

  • All adults should have their BMI calculated periodically by their healthcare provider.
  • All adults, no matter what their weight or body mass, should be regularly counseled about the benefits of a healthful diet and physical activity.

Osteoporosis

As the large “Baby Boom” generation moves beyond 50 years of age, the number of older people with thin and brittle bones is expected to rise sharply. Half of all American women over 50 years old will break a bone because of osteoporosis and so will 1 in 4 men, warned the U.S. Surgeon General. Fracturing the hip or spine often starts a depressing and socially isolating downward spiral of pain, disability, and deformity for an elderly person. Being immobilized in this way often means losing independence. The consequences can be depressing or even deadly.

Finding out if your bones have become dangerously porous and treating the problem can help reduce your risk of a fracture. An industry-funded study in 2001 estimated that only 12 percent of women 65 years of age or older with osteoporosis or osteopenia (low bone mass) had a Medicare-reimbursed bone marrow density x-ray. Your healthcare provider can now also use a calculator, called the FRAX tool, to better determine your risk of a hip, wrist, shoulder, or spine fracture after age 40. Available online or on paper, the calculator, developed by the World Health Organization, considers the bone density measurement and 9 other risk factors.

The National Osteoporosis Foundation recommends screening adults (men and women) as follows:

  • Men older than 70 years should be screened.
  • Women older than 65 years of age should be screened.
  • Adults who are middle aged and at risk should be screened. (For example, if they have already broken one of their bones as an adult, have a family history of osteoporosis or broken bones, use tobacco, or weigh less than 127 pounds. Other risk factors include physical inactivity and certain medications and therapies.)

Osteoporosis screening guidelines for men published in May 2008 by the American College of Physicians point out that this condition is underdiagnosed in men. Their guidelines include hypertension (140/90 mm Hg or higher, or you take antihypertensive medications), diabetes, overweight, a family history of early heart disease, a low level of the “good” HDL cholesterol (less than 40 mg/dL), or a high total and high LDL cholesterol. With just two risk factors, you fit into a category that benefits from closer monitoring.

On what age to stop, the U.S. Preventive Services Task Force says this: After age 65, you may not need to keep getting tested. Lipid levels are less likely to increase at this age; however, anyone over age 65 who has never been tested should have their cholesterol levels measured.

Thyroid Dysfunction

Thyroid disease is more common than diabetes or heart disease. A problem in this hormone-producing gland can affect every system and cell in your body, leaving you vulnerable to heart disease, osteoporosis, and other illnesses. Many people have underactive or overactive thyroids but do not know it because the signs are vague: fatigue, mood swings, forgetfulness, weight gain, depression, even dry and coarse skin and hair.

About 1 in 8 American women will develop a thyroid disorder. An underactive thyroid (hypothyroidism) is more common in women than men and often hits hardest during pregnancy, midlife, and older age.

Opinions vary on who can benefit from screening and at what age to begin.

The U.S. Preventive Services Task Force reviewed the evidence for and against screening in 2004 and announced it could not determine the balance of benefits and harms of screening asymptomatic adults for thyroid disease.

The American Thyroid Association recommends the following: Everyone over 35 years of age should be screened for thyroid disorders, with women a particular concern. Get rechecked every 5 years or sooner if you have symptoms or concerns.

The American Association of Clinical Endocrinologists advises the following: All women should be tested for hypothyroidism by 50 years of age. Get tested sooner if you have a family history of thyroid disease. If you have symptoms or risk factors, no matter what your age or sex, it is appropriate to get tested. For other adults, the best recommendation may be to put thyroid testing (TSH, T4, T3) on your list of what to discuss with your healthcare provider. For example, you can ask about the value of thyroid testing if you are pregnant or planning to become pregnant. As you age and experience what seem to be natural the experts tend to think. Prevention signs of aging, particularly if you are a woman, be alert to the possibility of thyroid problems.

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