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prev.cancer-screening.core.v1PRODUCTION
prev.cancer-screening.core.v1

Preventive cancer screening (adult)

general_internal_medicinechronicadult
Hard-required inputs
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Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm preventive screening scope: asymptomatic adult, life expectancy ≥10 yr (below which lead-time + overdiagnosis harm > benefit → STOP-screening). Excludes diagnostic workup of known symptoms/lesions and prior-cancer survivorship surveillance (USPSTF 2021; ACS 2018)

Inputs
3
Actions
0
Advance rule
Set
Advance when

Asymptomatic, eligible, ≥10-yr life expectancy confirmed

Patient inputs (19)

Age sets pre-test prevalence (the Bayesian prior) and eligibility window for every modality (USPSTF 2021/2024)

Breast/cervical screening in female; prostate in male; modifies prevalence prior (USPSTF 2024; USPSTF 2018)

Prior colonoscopy/mammogram/Pap/LDCT dates + findings set the next interval and the conditional post-test prior (USPSTF 2021; USMSTF 2020)

Screening benefit requires ≥10-yr life expectancy; below that the lead-time + overdiagnosis harm exceeds benefit → STOP-screening logic (USPSTF 2021; ACS 2018)

Lynch/BRCA1/BRCA2/Li-Fraumeni/FAP set very high prior → earlier + more frequent screening, different modality (NCCN 2024)

≥20 pack-yr + age 50-80 + quit <15 yr = LDCT-eligible; also PLCOm2012 input — drives lung-ca prior (USPSTF 2021 PMID 33687470)

First-degree relative with breast/colon/ovarian/prostate cancer raises pre-test prevalence and shifts age/modality (USPSTF 2024; ACS 2018; NCCN 2024)

Cirrhosis of any etiology = HCC pre-test prevalence high enough that US ± AFP q6mo exceeds the testing threshold (AASLD 2023 PMID 37199193)

Chronic HBV at sufficient risk (PAGE-B / ethnicity / family hx) warrants HCC surveillance even without cirrhosis (AASLD 2023)

Dense breasts lower mammography sensitivity (test-characteristic shift); supplemental MRI if dense + high lifetime risk (USPSTF 2024; ACR 2023)

FIT sens ~74% CRC / spec ~94%; a positive FIT raises post-test prob enough to mandate diagnostic colonoscopy (USPSTF 2021; USMSTF 2017)

Primary hrHPV sens ~90-95% > cytology; 16/18 genotype → immediate colposcopy, other hrHPV+ → reflex cytology triage (USPSTF 2018; ASCCP 2019)

HPV vaccination does NOT change screening interval per USPSTF 2018 / ACS 2020 (lowers prevalence over time but protocol unchanged)

Pregnancy defers/modifies screening (mammography deferred; cervical may continue per ASCCP; LDCT/colonoscopy deferred) — special-population branch

Prior-cancer survivors follow survivorship surveillance, not average-risk screening — different prior + protocol (NCCN survivorship 2024)

Shared-decision PSA in men 55-69; low specificity → MRI/PI-RADS reflex before biopsy (USPSTF 2018 PMID 29801017; AUA 2023)

AFP adjunct to US q6mo for HCC surveillance; GALAD combines AFP/AFP-L3/DCP for higher sens (AASLD 2023)

Liver US q6mo for HCC surveillance in cirrhosis; sensitivity for early HCC ~45-63%, AFP adjunct raises it (AASLD 2023)

Mantle/chest radiation age 10-30 → very high breast prior → annual MRI + mammo from age 25-30 (NCCN 2024; ACS 2022)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (7)

7 need judgement
  • informationallife_threateninglirads_5_definite_hcc_on_surveillance — AASLD 2023
    LI-RADS 5 definite HCC on surveillance imaging in cirrhosis — surveillance has converted to diagnosis
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepositive_screen_high_PPV_route_to_diagnostic_workup — Lung-RADS/BI-RADS/LI-RADS
    Lung-RADS 4 (PPV >15%), BI-RADS 5 (PPV >95%), positive FIT/FIT-DNA, hrHPV 16/18+, LI-RADS 4-5 — post-test probability now high enough that the harm of NOT working up exceeds the harm of the diagnostic cascade
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverehereditary_cancer_syndrome_confirmed — NCCN 2024
    Confirmed Lynch (MLH1/MSH2/MSH6/PMS2 — CRC lifetime up to ~50-80%), BRCA1/2 (breast ~55-72% lifetime), Li-Fraumeni (TP53), or FAP (APC, near-100% CRC) — very high prior requiring earlier + more frequent multi-organ surveillance
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderaterisk_model_crosses_action_threshold_expand_or_intensify — Tammemägi/ACR/USPSTF2019
    PLCOm2012 6-yr ≥1.3-1.7% (→ LDCT eligible despite categorical miss), Tyrer-Cuzick lifetime ≥20% (→ add annual MRI), Gail/BCRAT 5-yr ≥1.67% (→ chemoprevention), or GALAD-elevated in cirrhosis — the calculated prior crosses the action threshold
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatefalse_positive_cascade_and_overdiagnosis_harm — NLST/ERSPC
    A positive screen in a low-prior context is much more likely false-positive (LDCT 96.4% of positives FP over 3 rounds — NLST) or overdiagnosed (prostate ERSPC incidence RR 1.57 vs mortality RR 0.79; mammography ~10-20% overdiagnosis) — the harm side of the Bayesian ledger
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildpretest_prevalence_below_testing_threshold_do_not_screen — USPSTF/AASLD
    Age below modality lower bound, life expectancy <10 yr, or risk tier too low (e.g., HCC without cirrhosis/high-risk-HBV; cervical <21; CRC <45 average-risk; PSA ≥70) — pre-test prevalence × harm of false-positive cascade + overdiagnosis exceeds expected benefit
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildstop_screening_life_expectancy_or_age_bound — USPSTF/ACS
    Life expectancy <10 yr OR age exceeds modality upper bound (mammo >74, CRC >85, cervical >65 with adequate prior negatives, PSA ≥70, LDCT quit >15 yr or curative-surgery-ineligible, HCC if not transplant/treatment candidate) — the deprescribing-equivalent
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

RISK_STRATIFICATIONoptionalDrives screening
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Recommended regimen

Lung — LDCT (USPSTF 2021 Grade B PMID 33687470; NLST PMID 21714641; NELSON PMID 31995683)
axis: screening_modality_lung
Selected axis "Lung — LDCT (USPSTF 2021 Grade B PMID 33687470; NLST PMID 21714641; NELSON PMID 31995683)" by default fallback (first axis)
  • low_dose_chest_ct_annual
    first line
    imaging_screen
    LDCT annually, age 50-80, ≥20 pack-yr, current or quit <15 yr • imaging • annual
    NLST (Aberle NEJM 2011 PMID 21714641): 20% lung-ca mortality RR + 6.7% all-cause RR vs CXR; 96.4% of positives false-positive over 3 rounds. NELSON (de Koning NEJM 2020 PMID 31995683): cumulative lung-ca death RR 0.76 men / 0.67 women at 10 yr with only 2.1% referral rate (volumetric Lung-RADS reduces FP).
  • plco_m2012_risk_model_eligibility
    add on
    risk_model
    PLCOm2012 6-yr risk ≥1.3-1.7% threshold • n/a • at eligibility assessment
    triggers: borderline_pack_year_or_quit_interval, risk_model_expansion
    Expands LDCT to higher-yield candidates missed by categorical pack-year criteria (Tammemägi NEJM 2013).
  • smoking_cessation_pharmacotherapy_varenicline
    add on
    cessation
    Varenicline 1 mg BID × 12 wk (or NRT/bupropion) at every screen visit • PO • per cessation protocol
    triggers: active_smoker_in_lung_screening_program
    LDCT mortality benefit is conditional on cessation; integrate at each screen (USPSTF 2021).

outpatient playbook — drug actions (2)

  1. 1. tamoxifen 20 mg or raloxifene 60 mg daily × 5 yr
    20 mg (tamoxifen) / 60 mg (raloxifene) • PO • daily
    trigger: Gail/BCRAT 5-yr risk ≥1.67% and shared decision (USPSTF 2019)
    Breast cancer risk-reducing therapy; weigh VTE/endometrial harm (USPSTF 2019)
  2. 2. smoking cessation pharmacotherapy (varenicline preferred)
    1 mg BID • PO • BID × 12 wk
    trigger: Active smoker in lung-screening program (USPSTF 2021)
    LDCT benefit conditional on cessation — integrate at each screen

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Routine preventive/wellness visit — age/sex-appropriate cancer screening due (USPSTF 2021/2024); Known hereditary cancer syndrome (Lynch/BRCA/Li-Fraumeni/FAP) requiring intensified surveillance (NCCN 2024); Overdue or never-screened patient identified at any encounter (USPSTF 2021).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Preventive cancer screening (adult)** (prev.cancer-screening.core.v1).
Phenotype framing: Average-risk vs high-risk pathway, AND true-positive (early cancer) vs false-positive (benign nodule, inflammatory polyp, dense-tissue artifact, BPH-driven PSA) — the false-positive cascade and overdiagnosis are encoded as harm data, not prose. Screen-detected positive routes to the dx engine; screen-negative returns to interval (USPSTF 2021; NLST FP 96.4%)
Scope: Confirm preventive screening scope: asymptomatic adult, life expectancy ≥10 yr (below which lead-time + overdiagnosis harm > benefit → STOP-screening). Excludes diagnostic workup of known symptoms/lesions and prior-cancer survivorship surveillance (USPSTF 2021; ACS 2018)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Lung — LDCT (USPSTF 2021 Grade B PMID 33687470; NLST PMID 21714641; NELSON PMID 31995683)**.
1. low_dose_chest_ct_annual LDCT annually, age 50-80, ≥20 pack-yr, current or quit <15 yr imaging annual (imaging_screen, first line) — NLST (Aberle NEJM 2011 PMID 21714641): 20% lung-ca mortality RR + 6.7% all-cause RR vs CXR; 96.4% of positives false-positive over 3 rounds. NELSON (de Koning NEJM 2020 PMID 31995683): cumulative lung-ca death RR 0.76 men / 0.67 women at 10 yr with only 2.1% referral rate (volumetric Lung-RADS reduces FP).
2. plco_m2012_risk_model_eligibility PLCOm2012 6-yr risk ≥1.3-1.7% threshold n/a at eligibility assessment (risk_model, add on) — Expands LDCT to higher-yield candidates missed by categorical pack-year criteria (Tammemägi NEJM 2013).
3. smoking_cessation_pharmacotherapy_varenicline Varenicline 1 mg BID × 12 wk (or NRT/bupropion) at every screen visit PO per cessation protocol (cessation, add on) — LDCT mortality benefit is conditional on cessation; integrate at each screen (USPSTF 2021).

Setting playbook (outpatient) — Set the pre-test prevalence prior (age/sex/risk-model), order the age/sex/risk-appropriate screen, apply PPV reasoning to positives, route follow-up, document shared decisions + harms, schedule recall, and apply STOP-screening logic when harm exceeds benefit (USPSTF 2021/2024/2018; AASLD 2023)
4. tamoxifen 20 mg or raloxifene 60 mg daily × 5 yr 20 mg (tamoxifen) / 60 mg (raloxifene) PO daily — Gail/BCRAT 5-yr risk ≥1.67% and shared decision (USPSTF 2019) (Breast cancer risk-reducing therapy; weigh VTE/endometrial harm (USPSTF 2019))
5. smoking cessation pharmacotherapy (varenicline preferred) 1 mg BID PO BID × 12 wk — Active smoker in lung-screening program (USPSTF 2021) (LDCT benefit conditional on cessation — integrate at each screen)

Non-pharmacologic actions:
- Order LDCT if eligible (or PLCOm2012-expanded) — document 96.4% false-positive + overdiagnosis (USPSTF 2021; NLST PMID 21714641)
- Order biennial mammography 40-74; add MRI if Tyrer-Cuzick ≥20% (USPSTF 2024; ACR 2023)
- Order hrHPV-primary q5yr (30-65, 2025 WPSI preferred) or cytology q3yr (21-29) (USPSTF 2018)
- Order colonoscopy q10yr / FIT annual / FIT-DNA q1-3yr / CTC q5yr (USPSTF 2021; ACS 2018)
- Shared-decision PSA 55-69; MRI/PI-RADS reflex before biopsy (USPSTF 2018; AUA 2023)
- Order US ± AFP q6mo in cirrhosis / high-risk HBV; GALAD adjunct (AASLD 2023)
- Refer to genetics if hereditary syndrome criteria met (NCCN 2024)
- HPV vaccination catch-up through age 26 if unvaccinated (ACIP 2019)
- Patient education: test sensitivity/specificity, PPV, false-positive cascade, overdiagnosis, value of stopping when harm dominates (USPSTF 2021)

AVOID / contraindication checks:
- No_ldct_if_life_expectancy_lt_10yr_or_unable_unwilling_curative_surgery (USPSTF 2021 PMID 33687470)
- Stop_ldct_once_quit_gt_15yr (USPSTF 2021 — prevalence falls below benefit threshold)
- Shared_decision_required_document_false_positive_96pct_and_overdiagnosis (USPSTF 2021; NLST PMID 21714641)
- Special_pop:pregnancy_defer_ldct_unless_compelling (radiation; defer to postpartum)
- Special_pop:prior_lung_cancer_survivor_use_survivorship_surveillance_not_screening (NCCN 2024)

Monitoring

Regimen monitoring:
- annual ldct while eligible age 50 to 80 (USPSTF 2021)
- lung rads structured reporting PPV by category (ACR Lung-RADS 2022)
- stop screening review each visit life expectancy and quit interval (USPSTF 2021)

Setting (outpatient) monitoring:
- LDCT annually 50-80 while eligible (USPSTF 2021)
- Mammography biennially 40-74 (USPSTF 2024)
- hrHPV q5yr / cytology q3yr per age band (USPSTF 2018; 2025 WPSI)
- Colonoscopy q10yr or FIT annual or FIT-DNA q1-3yr (USPSTF 2021)
- PSA q1-2yr 55-69 if shared decision to screen (USPSTF 2018)
- US + AFP q6mo in cirrhosis (AASLD 2023)
- Post-polypectomy surveillance per USMSTF 2020 risk strata

Follow-up plan: STOP-screening / survivorship logic (the deprescribing-equivalent): discontinue when life expectancy <10 yr, age exceeds the upper bound (mammo >74, CRC >85, cervical >65 with adequate prior negatives, PSA ≥70, LDCT after 15 yr quit or curative-surgery-ineligible, HCC if not transplant/treatment candidate). Patient education on false-positive rate (LDCT 96.4% over 3 rounds — NLST), overdiagnosis (mammography ~10-20%, prostate substantial), and the value of NOT screening when harm dominates (USPSTF 2021; ACS 2018)
- Close-out criterion: Stop-screening decision OR continued-interval education delivered and documented

Monitoring phase: Interval + recall: LDCT annually while eligible 50-80 (USPSTF 2021); mammography biennially 40-74 (USPSTF 2024); cytology q3yr 21-29, hrHPV q5yr or co-test q5yr 30-65 (USPSTF 2018; 2025 WPSI hrHPV-primary preferred 30-65); colonoscopy q10yr / FIT annual / FIT-DNA q1-3yr / CTC q5yr (USPSTF 2021); PSA q1-2yr 55-69 if shared decision to screen (USPSTF 2018); AFP + US q6mo in cirrhosis (AASLD 2023); post-polypectomy surveillance per USMSTF 2020 risk strata

Disposition

Current setting: outpatient — Set the pre-test prevalence prior (age/sex/risk-model), order the age/sex/risk-appropriate screen, apply PPV reasoning to positives, route follow-up, document shared decisions + harms, schedule recall, and apply STOP-screening logic when harm exceeds benefit (USPSTF 2021/2024/2018; AASLD 2023)

Disposition criteria:
- Continue per interval if results negative and still eligible (USPSTF 2021; ACS 2018)
- Refer to specialist diagnostic engine for positive screen (USPSTF 2021)
- STOP screening when life expectancy <10 yr or age exceeds modality upper bound — deprescribing-equivalent (USPSTF 2021; ACS 2018)

Escalation triggers (move to higher acuity):
- Lung-RADS 4 → pulmonology/thoracic surgery; route onc.lung-cancer.core.v1 (ACR Lung-RADS 2022)
- BI-RADS 4-5 → breast surgery/biopsy (ACR BI-RADS; USPSTF 2024)
- Advanced adenoma or CRC on colonoscopy → GI/oncology (USMSTF 2020)
- PSA elevated/rising → urology mpMRI/PI-RADS ± biopsy (AUA 2023)
- LI-RADS 4-5 → hepatology/transplant oncology; route gi.hcc.core.v1 (AASLD 2023)
- Hereditary syndrome confirmed → NCCN high-risk protocol + cascade testing (NCCN 2024)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] LI-RADS 5 definite HCC on surveillance imaging in cirrhosis — surveillance has converted to diagnosis
- [SEVERE] Lung-RADS 4 (PPV >15%), BI-RADS 5 (PPV >95%), positive FIT/FIT-DNA, hrHPV 16/18+, LI-RADS 4-5 — post-test probability now high enough that the harm of NOT working up exceeds the harm of the diagnostic cascade
- [SEVERE] Confirmed Lynch (MLH1/MSH2/MSH6/PMS2 — CRC lifetime up to ~50-80%), BRCA1/2 (breast ~55-72% lifetime), Li-Fraumeni (TP53), or FAP (APC, near-100% CRC) — very high prior requiring earlier + more frequent multi-organ surveillance

Citations

- USPSTF 2018-2024 cancer screening recommendation statements + ACS 2018 colorectal + AASLD 2023 HCC + NCCN 2024 hereditary high-risk; 2025 WPSI cervical hrHPV-primary [PMID:33687470](https://pubmed.ncbi.nlm.nih.gov/33687470/)
- Cited evidence (PMID 21714641) [PMID:21714641](https://pubmed.ncbi.nlm.nih.gov/21714641/)
- Cited evidence (PMID 31995683) [PMID:31995683](https://pubmed.ncbi.nlm.nih.gov/31995683/)
- Cited evidence (PMID 38687503) [PMID:38687503](https://pubmed.ncbi.nlm.nih.gov/38687503/)
- Cited evidence (PMID 30140884) [PMID:30140884](https://pubmed.ncbi.nlm.nih.gov/30140884/)

Last reconciled with current guidelines: 2026-05-16.
References
  • USPSTF 2018-2024 cancer screening recommendation statements + ACS 2018 colorectal + AASLD 2023 HCC + NCCN 2024 hereditary high-risk; 2025 WPSI cervical hrHPV-primary — PMID:33687470
  • Cited evidence (PMID 21714641) — PMID:21714641
  • Cited evidence (PMID 31995683) — PMID:31995683
  • Cited evidence (PMID 38687503) — PMID:38687503
  • Cited evidence (PMID 30140884) — PMID:30140884