CancerScreening-Bazamoozi.ppt

Transcript CancerScreening-Bazamoozi.ppt

Dr.Azarm

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INTRODUCTION

Dr.Azarm

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INTRODUCTION

 Cancer deaths exceed seven million worldwide each year, despite overwhelming evidence that many malignancies are preventable  nearly half a million people die from cancer each year in the United States (US) alone  It is estimated that 50 percent of cancer is preventable

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INTRODUCTION

 risk factors (account for two-thirds of all cancers in the US –tobacco use, –excess weight, –poor diet, –inactivity

Dr.Azarm

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INTRODUCTION

 nine modifiable risks were identified as the cause of 35 percent of cancer deaths worldwide: –smoking, –alcohol use, –diet low in fruit and vegetables, –excess weight, –inactivity, –unsafe sex, –urban air pollution, –use of solid fuels, and Harvard Report on Cancer Prevention Volume 2: Prevention of Human Cancer. Cancer Causes and Control 1997; 8:S1. –contaminated injections in health-care settings

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INTRODUCTION

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Lifestyle issues which promote cancer are also risk factors for other diseases, such as stroke, heart disease, and diabetes.

Dr.Azarm

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TOBACCO USE

–kills approximately 5 million people each year –mostly through 

malignancy,



cardiovascular, and



respiratory disease

–Approximately one-half of all smokers die of a

tobacco-related disease, and

–adult smokers lose an average of 13 years of life

due to this addiction

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TOBACCO USE

–Smoking is responsible for approximately 30 percent of all cancer-related deaths in the US –lung cancer, increasing risk 10 to 20-fold –causative factor for  leukemia as well as cancers of  the oral cavity,  nasal cavity,  paranasal sinuses,  nasopharynx,  larynx,  esophagus,  pancreas, liver, stomach, cervix, kidney, large bowel, and bladder

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TOBACCO USE

–smoking to more aggressive prostate

cancers

–Smoking cessation leads to reduced risk of most tobacco-related diseases and a decrease in all cause mortality –The health benefits of quitting can be seen at all ages and can be measured almost immediately after cessation

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DIET -Dietary fat

–No clear link has been found between total fat intake and colon or breast cancer but the data are more convincing for prostate cancer and endometrial cancer –A diet high in animal fat may be an important factor in the development of prostate cancer  intake of large amounts of alpha-linoleic acid and low amounts of linoleic acid appear to increase risk  serum levels of testosterone decrease their fat intake are lower in men who

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DIET -Red meat

–elevate risk of colorectal cancer in both men and women –several factors have been suggested including heme content in the meat, animal fat, and carcinogens produced when the meat is cooked at high temperatures.

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DIET -Fruits and vegetables

–no association was seen between either total or specific category of fruit and vegetable intake and colon cancer risk T I A U Prospective study of fruit and vegetable consumption and incidence of colon and rectal cancers. Michels KB; Edward Giovannucci; Joshipura KJ; Rosner BA; Stampfer MJ; Fuchs CS; Colditz GA; Speizer FE; Willett WC S O J Natl Cancer Inst 2000 Nov 1;92(21):1740-52.

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DIET -Fruits and vegetables

–Evidence is stronger for a link between prostate cancer and tomato products – Lycopene , a carotenoid found in tomatoes, has been postulated to be responsible for this benefit but there are no data from well-designed clinical trials to support this hypothesis T I A U Prospective study of fruit and vegetable consumption and incidence of colon and rectal cancers. Michels KB; Edward Giovannucci; Joshipura KJ; Rosner BA; Stampfer MJ; Fuchs CS; Colditz GA; Speizer FE; Willett WC S O J Natl Cancer Inst 2000 Nov 1;92(21):1740-52.

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DIET -Dairy

–relationship of dairy food intake and ovarian cancer found no evidence of association in case control studies – OTHER three prospective cohort studies did demonstrate increased risk of ovarian cancer with high intake of dairy foods

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DIET -Fiber

–reduce the risk of heart disease [ 40,41 ] and diabetes [ 42,43 ], but its effect on cancer risk reduction is less certain

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DIET -Glycemic load

–Insulin and insulin-like growth factors promote cell proliferation, and it is hypothesized that hyperinsulinemia may promote certain cancers

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DIET -Omega-3 fatty acids

–there is no association between omega-3 fatty acids and cancer risk for 11 different types of cancer –Dietary supplementation with omega-3 fatty acids is unlikely to prevent cancer. T I A U Effects of omega-3 fatty acids on cancer risk: a systematic review. MacLean CH; Newberry SJ; Mojica WA; Khanna P; Issa AM; Suttorp MJ; Lim YW; Traina SB; Hilton L; Garland R; Morton SC S O JAMA. 2006 Jan 25;295(4):403-15.

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DIET -VITAMINS AND NUTRIENTS

–Several nutritional components have been shown to affect cancer risk, but the role of vitamins is less certain –neither vitamin C evaluated nor vitamin E supplementation was beneficial for prevention of the cancers TI AU SO Antioxidants vitamin C and vitamin e for the prevention and treatment of cancer. Coulter ID; Hardy ML; Morton SC; Hilton LG; Tu W; Valentine D; Shekelle PG J Gen Intern Med. 2006 Jul;21(7):735-44.

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DIET -VITAMINS AND NUTRIENTS

–A 2006 National Institutes of Health (NIH) consensus conference panel concluded that "present evidence is insufficient to recommend either for or against the use of multivitamin supplements by the American public to prevent chronic disease" TI AU SO Antioxidants vitamin C and vitamin e for the prevention and treatment of cancer. Coulter ID; Hardy ML; Morton SC; Hilton LG; Tu W; Valentine D; Shekelle PG J Gen Intern Med. 2006 Jul;21(7):735-44.

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DIET -VITAMINS AND NUTRIENTS

–It has not been proven that multivitamin and mineral supplements provide added benefit to a balanced, healthful diet T I The efficacy and safety of multivitamin and mineral supplement use to prevent cancer and chronic disease in adults: a systematic review for a National Institutes of Health state-of-the-science conference. A U Huang HY; Caballero B; Chang S; Alberg AJ; Semba RD; Schneyer CR; Wilson RF; Cheng TY; Vassy J; Prokopowicz G; Barnes GJ 2nd; Bass EB S O Ann Intern Med. 2006 Sep 5;145(5):372-85. Epub 2006 Jul 31.

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DIET -

VITAMINS AND NUTRIENTS -

Vitamin D

–may reduce the risk of colon cancer –Direct effects of vitamin D on colonic epithelial cells have been described –Vitamin D may also decrease cancer risk through improved calcium absorption –prostate cancer  did not demonstrate a relationship –breast cancer  may have a protective effect

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DIET -

VITAMINS AND NUTRIENTS -

Vitamin D

 in men was seen with an increment of 25 nmol/L in predicted 25(OH)D level in data derived from the US Health Professionals Follow-Up Study  This incremental level of serum 25(OH)D is not readily achieved with diet (one glass of milk would be predicted to increase the plasma level only by 2 to 3 nmol/L), and would require supplementation with at least 1500 IU vitamin daily

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DIET -

VITAMINS AND NUTRIENTS -

Vitamin D

 The authors raise a question whether limiting sun exposure, to decrease skin cancer risk, might increase the mortality risk for other cancers.

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DIET -

VITAMINS AND NUTRIENTS -

Calcium

–Increased calcium intake  reduced risk of colorectal cancer  increased risk of prostate cancer –700 mg/day   protection against colorectal cancer   without significantly increasing prostate cancer risk.

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DIET -

VITAMINS AND NUTRIENTS -

Calcium

–Calcium  in the colon –may offer protection by  Directly   Indirectly  fatty acids reducing epithelial cell proliferation, by binding secondary bile acids and ionized –total calcium over 2000 mg/day from both diet and supplementation was linked to a 20 percent increase in prostate cancer risk

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DIET -

VITAMINS AND NUTRIENTS -

Selenium

–higher intake of selenium variety of tumors decreases the risk of a –significant mortality reduction in cancers of  lung  colon  prostate –Selenium and Vitamin E Cancer Prevention Trial (SELECT) will provide valuable information on the overall risks and benefits of selenium

 DIET VITAMINS AND NUTRIENTS -

Folate

 a decrease in breast and colon cancer risk, especially in individuals who consume alcohol  supplementation with a multivitamin containing folic acid provided even greater benefit  increased dietary folate and vitamin B6 lowered colorectal cancer risk  reduced risk for pancreatic cancer intake  studies did not demonstrate an association between low dietary intake of folate and breast cancer

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DIET -

VITAMINS AND NUTRIENTS -

other vitamin supplements

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Vitamin E other day) (600 IU alpha-tocopherol every

–did not prevent invasive cancer in a 10 year

follow-up to the Women's Health Study, evaluating healthy women age 45 years and older (mean age 55 years)

–One study did find a decrease in risk for prostate cancer with vitamin E supplementation in male smokers

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DIET -

VITAMINS AND NUTRIENTS -

other vitamin supplements

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Beta carotene

–may increase the incidence of lung cancer incidence and mortality in patients with risk factors (smokers or asbestos exposure) –Beta carotene did not decrease cancer incidence in studies of American women [ 110 ] and men

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DIET -

VITAMINS AND NUTRIENTS -

other vitamin supplements

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Beta carotene

–in rural China with baseline deficiencies in micronutrients  a combination of beta-carotene , selenium , and zinc –decreased the incidence of noncardia stomach cancer, –but not other intestinal malignancies

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ALCOHOL

–increases the risk of cancers of  colon,  breast  Oropharynx  esophagus –Moderate alcohol use  has beneficial effects on cardiovascular health,  consumption of as little as one drink per day has been associated with an increase cancer risk

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ALCOHOL

 mechanisms –solvent properties may allow carcinogens to penetrate cell membranes –increases estrogen levels –impacts folate metabolism –act as an irritant, causing increased cell production –transporter carrying carcinogens –as a prometabolite for identified carcinogens

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PHYSICAL INACTIVITY

 Decreased physical activity  increase the risk for cancer,  in addition to multiple other diseases  Over 60 percent of US adults are not regularly active,  including 25 percent who are almost entirely sedentary  sedentary lifestyle is associated with 5 percent of cancer deaths

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PHYSICAL INACTIVITY

–Physical activity is associated with a decreased risk of colon and breast cancer –negative correlation between moderate to strenuous exercise and ER-negative, but not ER positive, breast cancer –activity offers some protection against endometrial and prostate cancer –physical activity may reduce the risk of lung cancer

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PHYSICAL INACTIVITY

 the protective effect of activity goes beyond its impact on body weight

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PHYSICAL INACTIVITY

 mechanisms –reduction in circulating levels of insulin, hormones, and other growth factors –impact on prostaglandin levels; improved immune function, and –altered bile acid metabolism

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PHYSICAL INACTIVITY

 Physical activity during certain periods of life, such as adolescence, may offer additional protection against disease  The optimal duration, intensity, and frequency of physical activity that may afford cancer protection is unknown.

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EXCESS WEIGHT

–65 percent of US adults are overweight –over 30 percent are considered obese

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EXCESS WEIGHT

 with an increase in the risk of multiple cancers including –colorectal, –postmenopausal breast, –endometrial, renal, and –esophageal cancer, with  a population attributable risk from –9 percent (postmenopausal breast cancer) –to 39 percent (endometrial cancer)

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EXCESS WEIGHT

 Obesity may also increase risk for cancer of –prostate, –liver, –gallbladder, –pancreas, –stomach, –ovary, and –cervix –non-Hodgkin's lymphoma –multiple myeloma

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EXCESS WEIGHT

 obesity in the US may account for –14 percent of cancer deaths in men and –20 percent of cancer deaths in women

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EXCESS SUN EXPOSURE

–Over 1 million cases of skin cancer, including basal cell and squamous cell carcinoma, are diagnosed each year –over 59,000 cases of malignant melanoma in the US in 2005 [ 9 ], and the incidence continues to rise –most skin cancers are curable –Radiation from the sun is the primary cause  both melanomatous and non-melanomatous skin cancer.

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EXCESS SUN EXPOSURE

–correlate with total lifetime sun exposure –Cumulative sun exposure may also increase melanoma risk –repeated intense exposures leading to blistering burns may be even more dangerous

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EXCESS SUN EXPOSURE

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Recommendations for sun protection

–All individuals should limit the time spent in the sun,  especially between the hours of 10 am and 3 pm, –wear hats, sunglasses, and other protective clothing, –use sunscreen

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EXCESS SUN EXPOSURE

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Recommendations for sun protection

–majority of lifetime sun exposure usually occurs during childhood and adolescence –protective behaviors early in life will provide the greatest benefit –Organization recently recommended against tanning bed use by anyone under the age of 18

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INFECTION

–17 percent of all new cancers worldwide are due to infections –Viruses may increase cancer risk through  cellular transformation,  disruption of cell cycle control,  increased cell turnover rates,  immune suppression

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INFECTION

 anogenital cancers [  Human papillomavirus (HPV) with cervical and other Hepatitis B (HBV) and C (HCV) with hepatocellular carcinoma [ 141 ] 140 ]  Human T-cell lymphotropic virus (HTLV-I) with adult T cell leukemia [ 142 ]  Human immunodeficiency virus (HIV-I) with Kaposi sarcoma and non-Hodgkin's lymphoma [ 9 ]  Human herpes virus 8 (HHV-8) with Kaposi sarcoma and primary effusion lymphoma [ 143,144 ]  Epstein-Barr virus (EBV) with Burkitt's lymphoma [ 143  ] Helicobacter pylori (H. pylori) with gastric cancer

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INFECTION

–The majority of these viruses are spread through contact with infected blood or body fluids –Vaccinations for HBV and HPV are particularly promising –Excess alcohol use may play a role in cancer development in patients with chronic HBV and HCV infections and should be avoided –antiviral therapy may reduce the risk of cancer –Retroviral therapy for HIV infection reduce the incidence of AIDS-related lymphoma

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INFECTION

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CHEMOPREVENTION

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Selective estrogen receptor modulators

and breast cancer -Tamoxifen

–an estrogen receptor antagonist with both estrogen agonist and antagonist properties –It is approved in the US for both primary and secondary prevention in high-risk women

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CHEMOPREVENTION

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Selective estrogen receptor modulators

and breast cancer -Tamoxifen

–Breast Cancer Prevention Trial (NSABP P-I), –women at increased risk for breast cancer  age >60,  history LCIS,  calculated five year risk >1.66 percent according to the Gail model

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CHEMOPREVENTION

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Selective estrogen receptor modulators and

breast cancer -Tamoxifen –an approximate 50 percent reduction in the relative risk of both invasive and noninvasive (ie, ductal and lobular carcinomas in situ) breast cancer with tamoxifen. –Risk was reduced only for estrogen receptor positive tumors. –Women in the tamoxifen arm had an approximately two fold increased incidence in endometrial tumors (cancers and uterine sarcomas), pulmonary embolism, deep vein thrombosis (DVT), and stroke

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CHEMOPREVENTION

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Selective estrogen receptor modulators

and breast cancer -Tamoxifen

 Because of the potential for serious side effects, the US Preventive Services Task Force (USPSTF) has recommended against routine use of tamoxifen for breast cancer prevention in women of average risk.

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CHEMOPREVENTION

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Selective estrogen receptor modulators

and breast cancer -Raloxifene

–— as Raloxifene is a selective estrogen receptor modulator (SERM) that is currently approved for the prevention of osteoporosis, but not for the prevention of breast cancer –STAR trial suggest that raloxifene is as effective tamoxifen in reducing the incidence of invasive breast cancers in high-risk women, but with fewer of the most serious side effects associated with tamoxifen

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CHEMOPREVENTION

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Selective estrogen receptor modulators

and breast cancer -Raloxifene

–There are no data on the use of raloxifene in premenopausal women, and it should not be used in this group

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CHEMOPREVENTION

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Aspirin and other anti-inflammatory drugs

–reducing colorectal cancer risk, –and possibly effective for other cancers –may cause cell cycle arrest or apoptosis

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CHEMOPREVENTION

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Aspirin and other anti-inflammatory drugs

–The optimal dose of aspirin,  however has not been established [ 161 ].  Low dose aspirin (100 mg every other day) did not prevent total cancer death, or incidence of breast, colorectal, or lung cancer, when compared with placebo, at 10 year follow-up  Full dose aspirin ( 325 mg) taken daily for a minimum of five years –decrease the incidence of colorectal cancer in the Cancer Prevention Study II Nutrition Cohort

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CHEMOPREVENTION

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Aspirin and other anti-inflammatory drugs

–There is good evidence that chronic use of aspirin, at doses suggested to decrease the incidence of colorectal cancer,  increases the risk for gastrointestinal bleeding and hemorrhagic stroke  increases risk for renal failure and hypertension

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CHEMOPREVENTION

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Aspirin and other anti-inflammatory drugs

–USPSTF and the American Cancer Society do not recommend aspirin or NSAID use to prevent colorectal cancer for average risk patients

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CHEMOPREVENTION

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Finasteride and prostate cancer

–Compared to men in the placebo group,  the incidence of prostate cancer was decreased in the finasteride group (18.4 percent versus 24.4 percent)  but there was an increase in the absolute number and proportion of high grade tumors

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CHEMOPREVENTION

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Finasteride and prostate cancer

–Concerns about increased risk for high grade prostate cancer dampened enthusiasm for the use of finasteride as a chemopreventive agent –It is premature to recommend the use of finasteride as a chemopreventive agent in men at high risk for prostate cancer, but clinicians should feel comfortable about using finasteride in men with large-gland BPH

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CHEMOPREVENTION

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SUMMARY AND RECOMMENDATIONS

–Many cancers are preventable –Basic lifestyle changes  have a tremendous impact on the rates of cancer  also protect against other chronic diseases (cardiovascular disease, stroke, and diabetes)

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CHEMOPREVENTION

 General lifestyle recommendations include:  Avoid tobacco  Be physically active  Maintain a healthy weight  Eat a diet rich in fruits, vegetables, and whole grains, and low in saturated/trans fat  Limit alcohol  Protect against sexually transmitted infections  Avoid excess sun  Get regular screening

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CHEMOPREVENTION

Specific factors associated with cancer risk include the following: – Tobacco use is responsible for 90 percent of all lung cancer deaths, and is tied to multiple other cancers – The association of dietary fat, fruits, vegetables, and fiber with cancer risk is largely unconfirmed. – Red meat consumption may promote colorectal cancer – high intake of tomatoes probably decreases prostate cancer risk.

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CHEMOPREVENTION

Specific factors associated with cancer risk include the following: – Vitamin D may reduce the risk of colorectal and prostate cancer. – Calcium intake, at a minimum of 700 mg/day, may protect against colorectal cancer – but high calcium intake (>2000 mg/day) increases risk for prostate cancer.

– Folic acid in diet has been associated with a decreased risk of colon and breast cancer, especially in women who drink alcohol; – data on multivitamin supplementation are inconsistent

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CHEMOPREVENTION

Specific factors associated with cancer risk include the following: – Alcohol intake, even in moderate quantities, increases the risk for colon, breast, esophageal and oropharyngeal cancer.

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CHEMOPREVENTION

Specific factors associated with cancer risk include the following: – Physical activity is inversely related to risk for colon and breast cancer. – Excess weight increases the risk of multiple cancers.

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CHEMOPREVENTION

Specific factors associated with cancer risk include the following: – Skin cancer is directly related to sun exposure, and melanoma rates are increasing. – A history of blistering sunburns are of particular risk for melanoma; – cumulative sun exposure has more impact on non-melanoma cancers.

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CHEMOPREVENTION

Specific factors associated with cancer risk include the following: – HPV, HCV, HTLV1, HIV, EBV, and H pylori have been linked to human cancers. – Exposure prevention, screening, and early treatment for abnormal Pap smears and HIV infection can prevent cancer

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CHEMOPREVENTION

Specific factors associated with cancer risk include the following: – Chemoprevention may be helpful in high risk patients but risks and benefits should be weighed carefully.  Aspirin and NSAIDs offer protection against adenomatous polyps and colorectal cancer, but are not recommended for routine use in average risk patients.

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CHEMOPREVENTION

Specific factors associated with cancer risk include the following:  Tamoxifen decreases incidence of breast cancer in high risk women, but increases the risk for thromboembolic disease and early stage endometrial cancer.   Raloxifene is a reasonable alternative, but has not been evaluated in premenopausal women The use of finasteride as a chemopreventive agent should be discussed with men who are interested in preventing prostate cancer

 –What Is Cancer Screening?

 –Evaluation of a Screening Test  –Breast Cancer Screening  –Cervical Cancer Screening  –Colorectal Cancer Screening  –Skin Cancer Screening  –Prostate Cancer Screening  –Lung Cancer Screening  –Adherence to Cancer Screening  –Future of Screening

 The goal of cancer screening –detect cancer at an early stage when it is treatable and curable  For a screening test to be useful: –the test or procedure should detect cancer earlier than would occur otherwise, –there should be evidence that earlier diagnosis results in improved outcomes

 Advances in genetics and molecular biology –will make it possible to detect cancer at earlier and earlier stages along the carcinogenesis pathway –the line between prevention and screening may narrow further, as it has for colorectal and cervical cancers

 The National Cancer Policy Board estimated that appropriate use of screening among –persons aged 50 and older could reduce the mortality from colorectal cancer by 30% to 80%; –women aged 50 and older could reduce mortality from breast cancer by 25% to 30%, –women aged 18 and older could reduce the rate of cervical cancer mortality by 20% to 60%.

What Is Cancer Screening?

 lead to early detection of asymptomatic or unrecognized disease  acceptable  inexpensive tests or examinations  in a large number of persons  expeditiously to separate apparently well persons who probably have disease from those who probably do not.

What Is Cancer Screening?

 The main objective of cancer screening is to: – reduce morbidity and mortality from a particular cancer among persons screened

What Is Cancer Screening?

Characteristics of Screening Tests versus Diagnostic Tests Screening Applied to asymptomatic groups Lower cost per test Lower yield per test Lower adverse consequences of error Diagnosis

Applied to symptomatic individuals Higher cost; all necessary tests applied to identify disease Higher probability of case detection Failure to identify true positives can delay treatment and worsen prognosis

What Is Cancer Screening?

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cancers suitable for screening

–High morbidity and mortality, –high prevalence in a detectable preclinical state, –possibility of effective and improved treatment because of early detection, and –availability of a good screening test with high sensitivity and specificity, –low cost, and –little inconvenience and discomfort

What Is Cancer Screening?

 cancers suitable for screening

–Breast CA –Cervical CA –colorectal CA

Evaluation of a Screening Test

 If the test is

abnormal

, –what are the chances that disease is present?  If the test result is

normal

, –what are the chances that disease is absent?

Evaluation of a Screening Test

 The validity of a screening test – Sensitivity and specificity address the validity of screening tests  Sensitivity is the probability of testing positive if the disease is truly present. –As sensitivity increases,  false-negative decreases  Specificity is the probability of screening negative if the disease is truly absent. –A highly specific test  false-positive decreases

Evaluation of a Screening Test

 The validity of a screening test –Predictive value  is a function of sensitivity, specificity, and prevalence of disease  PV+ is an estimate of test accuracy in predicting presence of disease;  PV– is an estimate of the accuracy of the test in predicting absence of disease

Definitions of Criteria for Evaluating a Screening Test Screening Test Results

Positive Negative Sensitivity = TP/TP + FN x 100 Specificity = TN/FP + TN x 100 PV+ = TP/TP + FP x 100 PV– = TN/TN + FN x 100 Accuracy = TP + TN/TP + TN + FP + FN x 100

Truth (Diagnostic Classification) Cancer Present

TP FN

Cancer Absent

FP TN

FN, false-negative (number of subjects with cancer who are incorrectly classified as cancer-free by the test); FP, false-positive (number of cancer-free subjects who are incorrectly classified as having cancer by the test); PV, predictive value; TN, true-negative (number of cancer-free subjects who are correctly classified by the test); TP, true-positive (number of subjects with cancer who are correctly classified by the test).

Evaluation of a Screening Test

 Measures of Effectiveness –Potential benefits include  improved prognosis for those with screen-detected cancers,  the possibility of less radical treatment,  reassurance for those with negative test results,  resource savings if treatment costs are reduced because of less radical treatments

Evaluation of a Screening Test

 Measures of Effectiveness –The optimal outcome is a reduction in cancer mortality

Evaluation of a Screening Test

 Measures of Effectiveness –Potential negative effects of screening include  physical, economic, and psychological consequences of false-positives and false-negatives,  the potential for overdiagnosis,  the potential carcinogenic effects of screening,  the labeling phenomenon.

Evaluation of a Screening Test

 Measures of Effectiveness –Physicians should engage patients in discussions of the risks and benefits of cancer screening

Table 22-5: Screening Guidelines for Breast, Colorectal, Prostate, and Cervical Cancers for Selected Health Care Organizations

Br ea st ca nc er

Ty pe of Ca nc er American Cancer Society 20 U.S. Preventive Services Task Force 3

Ce rvi cal ca nc er Col ore cta l ca nc er Pro sta te ca nc er Annual mammography for women aged 40–69 y. No age cutoff. To the extent possible, a CBE should be performed at the time of mammography. Monthly BSE.

monthly.

20 136

Women aged 20–39 y should have a CBE from a health professional every 3 y and should perform BSE For all women who are, or have been, sexually active or who have reached age 21 y, Pap test and pelvic examination yearly with Pap tests or every 3 y with liquid-based tests. At or after age 30 y, women who have had 3 normal tests can be screened every 2–3 y. Women with risk factors (e.g., HPV infection) may require more frequent screening. Screening is not necessary for women who have had total hysterectomies unless the surgery was for treatment of cervical cancer. One of the following schedules for men and women aged 50 y and over at average risk: FOBT yearly; sigmoidoscopy every 5 y; FOBT + sigmoidoscopy every 5 y; colonoscopy every 10 y; DCBE every 5 y. Those at high risk for colorectal cancer should begin screening earlier and/or more frequently. PSA test and DRE should be offered annually, beginning at age 50 y, to men who have a life expectancy of at least 10 y. Men at high risk for cancer should start screening at 45 y. Men should be given the information needed to make informed decisions about prostate cancer screening. Recommends screening mammogram, with or without CBE, every 1–2 y. Pap test every 1–3 y for all women who are sexually active and/or have a cervix. No evidence to support an upper limit, but age 65 y can be defended in women with a history of normal and regular Pap tests. Screening for colorectal cancer is strongly recommended for men and women aged 50 y and over. Several screening modalities are effective. Good evidence has been shown that periodic FOBT reduces mortality from colorectal cancer, and there is fair evidence that sigmoidoscopy alone or in combination with FOBT reduces mortality. No direct evidence has been shown for either colonoscopy or DCBE. Evidence is insufficient to recommend for or against routine screening for prostate cancer using PSA testing or DRE.

National Cancer Institute's Physician Data Query (PDQ) System 1

Mammography every 1–2 y for women age 40 y and older. Women at higher risk should talk with their physicians about schedule. Evidence strongly suggests a decrease in mortality for regular screening with Pap tests in women who are sexually active or who have reached age 18 y. The upper limit at which such screening ceases to be effective is unknown. FOBT either annually or biennially using rehydrated or nonrehydrated stool specimens in people aged 50 y and over decreases mortality for colorectal cancer. Regular screening by sigmoidoscopy in people over age 50 y may decrease mortality from colorectal cancer. Evidence is insufficient to determine the optimal interval for such screening. Evidence is insufficient to establish that a decrease in mortality occurs with screening by DRE, transrectal ultrasound, or PSA.

Screening Guidelines for Breast, Colorectal, Prostate, and Cervical Cancers for Selected Health Care Organizations Type of Cancer American Cancer Society 20 U.S. Preventive Services Task Force 3 National Cancer Institute's Physician Data Query (PDQ) System 1

Breast cancer Annual mammography for women aged 40–69 y. No age cutoff. To the extent possible, a CBE should be performed at the time of mammography. Monthly BSE.

136

Women aged 20–39 y should have a CBE from a health professional every 3 y and should perform BSE monthly.

Recommends screening mammogram, with or without CBE, every 1–2 y. Mammography every 1–2 y for women age 40 y and older. Women at higher risk should talk with their physicians about schedule.

Table 22-5: Screening Guidelines for Breast, Colorectal, Prostate, and Cervical Cancers for Selected Health Care Organizations Type of Cance r

Cervic al cancer

American Cancer Society 20

For all women who are, or have been, sexually active or who have reached age 21 y, Pap test and pelvic examination yearly with Pap tests or every 3 y with liquid-based tests. At or after age 30 y, women who have had 3 normal tests can be screened every 2–3 y. Women with risk factors (e.g., HPV infection) may require more frequent screening. Screening is not necessary for women who have had total hysterectomies unless the surgery was for treatment of cervical cancer.

U.S. Preventive Services Task Force 3

Pap test every 1–3 y for all women who are sexually active and/or have a cervix. No evidence to support an upper limit, but age 65 y can be defended in women with a history of normal and regular Pap tests.

National Cancer Institute's Physician Data Query (PDQ) System 1

Evidence strongly suggests a decrease in mortality for regular screening with Pap tests in women who are sexually active or who have reached age 18 y. The upper limit at which such screening ceases to be effective is unknown.

Type of Cancer

Colorectal cancer

American Cancer Society 20 U.S. Preventive Services Task Force 3

One of the following schedules for men and women aged 50 y and over at average risk: FOBT yearly; sigmoidoscopy every 5 y; FOBT + sigmoidoscopy every 5 y; colonoscopy every 10 y; DCBE every 5 y. Those at high risk for colorectal cancer should begin screening earlier and/or more frequently. Screening for colorectal cancer is strongly recommended for men and women aged 50 y and over. Several screening modalities are effective. Good evidence has been shown that periodic FOBT reduces mortality from colorectal cancer, and there is fair evidence that sigmoidoscopy alone or in combination with FOBT reduces mortality. No direct evidence has been shown for either colonoscopy or DCBE.

National Cancer Institute's Physician Data Query (PDQ) System 1

FOBT either annually or biennially using rehydrated or nonrehydrated stool specimens in people aged 50 y and over decreases mortality for colorectal cancer. Regular screening by sigmoidoscopy in people over age 50 y may decrease mortality from colorectal cancer. Evidence is insufficient to determine the optimal interval for such screening.

Type of Cancer

Prostate cancer

American Cancer Society 20 U.S. Preventive Services Task Force 3

PSA test and DRE should be offered annually, beginning at age 50 y, to men who have a life expectancy of at least 10 y. Men at high risk for cancer should start screening at 45 y. Men should be given the information needed to make informed decisions about prostate cancer screening. Evidence is insufficient to recommend for or against routine screening for prostate cancer using PSA testing or DRE.

National Cancer Institute's Physician Data Query (PDQ) System 1

Evidence is insufficient to establish that a decrease in mortality occurs with screening by DRE, transrectal ultrasound, or PSA.

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Breast Cancer Screening

 lifetime breast cancer incidence is 7.8%,  Widely accepted techniques for breast cancer screening, –mammography, –clinical breast examination (CBE), and –breast self-examination (BSE). –No cancer screening test has been studied more than mammography (with or without CBE).

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Breast Cancer Screening

 Most trials have included women in their 40s,  two trials began accrual at age 45.  One of the Canadian trials [the first National Breast Cancer Screening Study (NBSS1)] was designed to examine mammography and CBE versus usual care for women in their 40s

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