A 49-year-old woman presents to her primary care physician for a general check up. She has not seen a primary care physician for the past 20 years but states she has been healthy during this time frame. She had breast implants placed when she was 29 years old but otherwise has not had any surgeries. She is concerned about her risk for breast cancer given her friend was recently diagnosed. Her temperature is 97.0°F (36.1°C), blood pressure is 114/64 mmHg, pulse is 70/min, respirations are 12/min, and oxygen saturation is 98% on room air. Physical exam is unremarkable. Which of the following is the most appropriate workup for breast cancer for this patient?

No intervention indicated at this time

A 57-year-old man presents for his yearly wellness visit. He says he has been feeling well and has no complaints. No significant past medical history or current medications. The patient reports a 35-pack-year smoking history but says he quit 5 years ago. His family history is significant for lung cancer in his father who died at age 67. His vital signs include: temperature 36.8°C (98.2°F), pulse 95/min, respiratory rate 16/min, blood pressure 100/75 mm Hg. Physical examination is unremarkable. Laboratory findings are significant for the following: Serum potassium 3.9 mEq/L Serum sodium 140 mEq/L Serum chloride 103 mEq/L Serum calcium 2.5 mmol/L BUN 15 mg/dL Creatinine 0.8 mg/dL Glucose 95 mg/dL Magnesium 1.7 mEq/L Phosphate 1.1 mmol/L Hemoglobin 14 g/dL Bicarbonate (HCO3-) 25 mEq/L Bilirubin, total 0.9 mg/dL Bilirubin, indirect 0.4 mg/dL AST 10 U/L ALT 19 U/L Alkaline phosphatase 40 U/L Albumin 3.6 g/dL Which of the following preventative screening tests is recommended for this patient at this time?

Low-dose CT scan (LDCT) of the chest

An 18-year-old man presents to his primary care provider before leaving for college. He has no complaints. His past medical history is significant for asthma, acne vulgaris, and infectious mononucleosis at age 16. His home medications include doxycycline and albuterol as needed. His family history is significant for colon cancer in his father at age 50, his paternal grandfather at age 55, and an uncle at age 45. His father underwent testing for mutations in the APC gene, which were negative. There is no family history of dental abnormalities or other malignancy. The patient denies any recent weight loss, abdominal pain, hematochezia, melena, or other changes in the appearance of his stools. This patient should be screened for colorectal cancer (CRC) under which of the following protocols?

Colonoscopy every 5 years beginning at age 40

Colonoscopy every 10 years beginning at age 50

Colonoscopy every 1-2 years beginning at age 25

Fecal occult blood testing annually beginning at age 40

A 65-year-old African American man presents for follow-up examination with a 6-month history of urinary hesitancy, weak stream, and terminal dribbling, which is refractory to a combination therapy of finasteride and tamsulosin. The patient’s past medical history is otherwise unremarkable. His father and brother were diagnosed with prostate cancer at the age of 55 years. His vital signs are within normal limits. The patient has a normal anal sphincter tone and a bulbocavernosus muscle reflex. Digital rectal exam (DRE) reveals a prostate size equivalent to 2 finger pads with a hard nodule and without fluctuance or tenderness. Serum prostate-specific antigen (PSA) level is 5 ng/mL. Which of the following investigations is most likely to establish a definitive diagnosis?

Magnetic resonance imaging (MRI)

A 19-year-old woman presents for a sports physical. She says she feels healthy and has no concerns. Past medical history is significant for depression and seasonal allergies. Current medications are fluoxetine and oral estrogen/progesterone contraceptive pills. Family history is significant for a sister with polycystic ovarian syndrome (PCOS). The patient denies current or past use of alcohol, recreational drugs, or smoking. She reports that she has been on oral birth control pills since age 14 and uses condoms inconsistently. No history of STDs. She is sexually active with her current boyfriend, who was treated for chlamydia 2 years ago. She received and completed the HPV vaccination series starting at age 11. Her vital signs include: temperature 36.8°C (98.2°F), pulse 97/min, respiratory rate 16/min, blood pressure 120/75 mm Hg. Physical examination is unremarkable. Which of the following are the recommended guidelines for cervical cancer screening for this patient at this time?

No cervical cancer screening is indicated at this time

Cytology (pap smear) and HPV DNA co-testing every 3 years

Cytology (pap smear) every 3 years

Cytology (pap smear) and HPV DNA co-testing every 5 years

A 19-year-old woman presents to the physician for a routine health maintenance examination. She has a past medical history of gastroesophageal reflux disease. She recently moved to a new city to begin her undergraduate studies. Her father was diagnosed with colon cancer at age 46. Her father's brother died because of small bowel cancer. Her paternal grandfather died because of stomach cancer. She takes a vitamin supplement. Current medications include esomeprazole and a multivitamin. She smoked 1 pack of cigarettes daily for 3 years but quit 2 years ago. She drinks 1–2 alcoholic beverages on the weekends. She appears healthy. Vital signs are within normal limits. Physical examination shows no abnormalities. Colonoscopy is unremarkable. Germline testing via DNA sequencing in this patient shows mutations in DNA repair genes MLH1 and MSH2. Which of the following will this patient most likely require at some point in her life?

Annual colonoscopy beginning at 20–25 years of age

Surgical removal of a desmoid tumor

Prophylactic proctocolectomy with ileoanal anastomosis

Measurement of carcinoembryonic antigen and CA 19-9 yearly

A 46-year-old man presents with increasing fatigue and weakness for the past 3 months. He works as a lawyer and is handling a complicated criminal case which is very stressful, and he attributes his fatigue to his work. He lost 2.3 kg (5.0 lb) during this time despite no change in diet or activity level. His past history is significant for chronic constipation and infrequent episodes of bloody stools. Family history is significant for his father and paternal uncle who died of colon cancer and who were both known to possess a genetic mutation for the disease. He has never had a colonoscopy or had any genetic testing performed. Physical examination is significant for conjunctival pallor. A colonoscopy is performed and reveals few adenomatous polyps. Histopathologic examination shows high-grade dysplasia and genetic testing reveals the same mutation as his father and uncle. The patient is concerned about his 20-year-old son. Which of the following is the most appropriate advice regarding this patient's son?

A genetic test followed by colonoscopy for the son should be ordered.

The son doesn't need to be tested now.

An immediate colonoscopy should be ordered for the son.

Screening can be started by 50 years of age as the son’s risk is similar to the general population.

The son should undergo a prophylactic colonic resection.

Cancer screening recommendations (by cancer type) for USMLE Step 1: High-Yield Diagnosis Lessons

Breast Cancer Screening - Mammo Mission

USPSTF: Biennial mammography for women 50-74 years. Individualize for ages 40-49.
ACS: Annual mammography for women 45-54, then biennial for ≥55. Option to start at 40.
High-Risk Screening: For patients with >20-25% lifetime risk (e.g., BRCA carriers, prior mantle radiation).
- Start annual Breast MRI + mammogram at age 30.

⭐ The Gail model assesses a woman's risk of developing invasive breast cancer over the next 5 years.

Cervical Cancer Screening - Pap Power Play

Ages 21-29: Pap smear (cytology) alone every 3 years.
Ages 30-65: Choice of:
- - Pap smear every 3 years.
- - High-risk HPV (hrHPV) testing every 5 years.
- - Co-testing (Pap + hrHPV) every 5 years.
Age >65: Stop screening if prior results negative & no history of CIN2+.

⭐ HPV types 16 and 18 are the culprits in ~70% of cervical cancers and high-grade cervical intraepithelial neoplasia (CIN).

Colorectal Cancer Screening - Colonoscopy Countdown

Colorectal Cancer Screening by Risk Level

Average-Risk: Start at age 45, continue to 75. Decision to screen from 76-85 is individualized.
Primary Options:
- Colonoscopy: every 10 years.
- FIT (Fecal Immunochemical Test): annually.
- sDNA-FIT (e.g., Cologuard): every 3 years.
1st-Degree Relative w/ CRC: Start at age 40 or 10 years before relative's diagnosis; repeat colonoscopy every 5 years.

⭐ Lynch Syndrome (HNPCC): Start colonoscopy at 20-25 years; repeat every 1-2 years.

Lung Cancer Screening - Smoker's Scan

Indication: Screen high-risk individuals to reduce lung cancer mortality.
Criteria (USPSTF):
- Age 50-80 years
- ≥20 pack-year smoking history
- Current smoker or have quit within the past 15 years
Method: Annual screening with low-dose computed tomography (LDCT).
Discontinuation:
- Quit smoking for >15 years
- Develops a life-limiting illness
- Reaches age 81

⭐ Annual screening with LDCT in high-risk patients is proven to reduce mortality from lung cancer, making it a critical preventive measure.

Prostate Cancer Screening - PSA Predicament

USPSTF Grade C for men aged 55-69 years; decision is individualized.
Screening not routinely recommended for average-risk men <'''55''' or >70 years.
Shared Decision-Making is Key: Discuss pros and cons before testing.
- Benefits: Potential ↓ in mortality.
- Harms: False positives (e.g., BPH, prostatitis), overdiagnosis, and treatment complications (incontinence, erectile dysfunction).
Consider earlier screening (40-45 yrs) for high-risk groups (African American, strong family history).

PSA Testing: Benefits, Limitations, and Screening Rationale

⭐ To prevent one death from prostate cancer, ~1,000 men must be screened and ~48 treated, highlighting the significant risk of overtreatment.

Cervical Cancer: Screen women 21-65. Pap smear every 3 years or, for ages 30-65, Pap + HPV co-testing every 5 years.

Breast Cancer: Biennial mammography for women aged 50-74. Start at age 40 for high-risk individuals.

Colorectal Cancer: Start screening at age 45. Colonoscopy every 10 years is a primary option.

Lung Cancer: Annual low-dose CT for adults 50-80 with a 20 pack-year smoking history.

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