What screenings are recommended for a 50-year-old male with no prior medical history (hx)?

Recommended Screening for a 50-Year-Old Male

A 50-year-old male with no medical history should undergo colorectal cancer screening as the priority, with colonoscopy every 10 years or annual fecal immunochemical testing (FIT) as first-tier options. 1

Colorectal Cancer Screening (Answer: A)

Colorectal cancer screening is the definitive recommendation at age 50 for average-risk individuals and represents the most evidence-based screening intervention at this age. 1

First-Tier Screening Options:

• Colonoscopy every 10 years - This is the gold standard screening method 1, 2
• Annual high-sensitivity fecal immunochemical test (FIT) - Equally recommended as a first-tier option 1, 2

Second-Tier Alternatives (if patient declines first-tier):

• CT colonography every 5 years 1, 2
• Multitarget stool DNA test every 3 years 1, 2
• Flexible sigmoidoscopy every 5 years 1, 2

Rationale:

The U.S. Multi-Society Task Force on Colorectal Cancer provides a strong recommendation with moderate-quality evidence for beginning screening at age 50 in non-African American average-risk persons. 1 This screening has demonstrated mortality reduction and prevention of metastatic disease. 2

Prostate Cancer Screening (Answer: B - NOT Routinely Recommended)

Prostate cancer screening at age 50 should NOT be performed routinely but requires shared decision-making discussion. 3

Current Evidence:

• The USPSTF (2018) recommends that for men aged 55-69 years, the decision to undergo PSA screening should be individualized after discussion of potential benefits and harms 3
• At age 50, routine PSA screening is not recommended - the evidence supports discussion beginning at age 55 3
• The net benefit is small: screening may prevent 1.3 deaths per 1000 men screened over 13 years, but causes significant harms including false positives, overdiagnosis, and treatment complications (1 in 5 men develop urinary incontinence, 2 in 3 develop erectile dysfunction after radical prostatectomy) 3

Exception - Earlier Discussion Warranted:

• African American men should have screening discussion at age 45 1, 4
• Men with first-degree relative diagnosed before age 65 should discuss at age 45 1
• Men with multiple first-degree relatives diagnosed before age 65 should discuss at age 40 1

For this average-risk 50-year-old male, prostate cancer screening is not indicated at this time. 3

Lung Cancer Screening (Answer: C - NOT Indicated)

Lung cancer screening is NOT recommended for this patient without smoking history. The question states "no hx nothing," which implies no significant smoking history. Lung cancer screening with low-dose CT is only indicated for individuals with substantial smoking history (typically 20-30 pack-years) and is not part of routine screening for average-risk 50-year-old males.

Breast Cancer Screening (Answer: D - NOT Applicable)

Breast cancer screening is not applicable to males unless there are specific high-risk conditions (such as BRCA mutations, Klinefelter syndrome, or strong family history), which are not mentioned in this case.

Additional Recommended Screenings at Age 50

While not listed in the options, a comprehensive approach should include:

Cardiovascular Screening:

• Lipid screening (total cholesterol and HDL) is recommended for men aged 40-75 years 4
• Repeat every 5 years if normal, more frequently if borderline 4
• Non-fasting samples are acceptable 4

Blood Pressure:

• Routine blood pressure screening should be performed at all ages

Critical Pitfalls to Avoid

• Do not delay colorectal cancer screening - Recent guidelines have lowered the age from 50 to 45 for average-risk individuals, making age 50 clearly within the screening window 4
• Do not perform single-panel guaiac FOBT during digital rectal examination - This has very low sensitivity and is not recommended 1
• Do not screen for prostate cancer without informed discussion - The harms may outweigh benefits, and patient values must be incorporated 3
• Do not assume flexible sigmoidoscopy alone is adequate - Studies show it would miss up to 38% of neoplastic polyps found only in the proximal colon 5