1
Q
The patient’s wishes determine the level of _______.
A
medical care
These wishes should be elicited before the terminal phase of illness and reviewed periodically.
2
Q
Information about advance directives can be obtained from which organizations?
A
- American Association of Retired Persons
- Choice in Dying
Contact details include: AARP - 202-434-2277, Choice in Dying - 212-366-5540.
3
Q
True or false: Some states allow physicians to assist patients who choose to end their lives.
A
TRUE
This subject is challenging from both an ethical and a medical point of view.
4
Q
Discussions of end-of-life decisions should involve which elements?
A
- Clear informed consent
- Waiting periods
- Second opinions
- Documentation
A full discussion of end-of-life management is provided in Chap. 12.
5
Q
The goal of cancer prevention and early detection is to reduce cancer mortality by preventing cancer in those at risk and effective _______.
A
screening
This involves specific interventions beyond just identifying and avoiding carcinogens.
6
Q
What is carcinogenesis?
A
A process that usually extends over years, involving discrete tissue and cellular changes
It results in aberrant physiologic processes.
7
Q
Public education on the avoidance of identified risk factors for cancer contributes to _______.
A
cancer prevention
Clinicians play a vital role as messengers in this process.
8
Q
What is a strong, modifiable risk factor for cardiovascular disease, pulmonary disease, and cancer?
A
Tobacco smoking
Smokers have an ~1 in 3 lifetime risk of dying prematurely from a tobacco-related disease.
9
Q
The number of cigarettes smoked per day is correlated with the risk of _______.
A
lung cancer mortality
Light- and low-tar cigarettes are not safer due to deeper inhalation.
10
Q
Those who stop smoking have a _______ lower 10-year lung cancer mortality rate compared to those who continue smoking.
A
30-50%
Some carcinogen-induced gene mutations may persist for years after smoking cessation.
11
Q
What is the risk of environmental tobacco smoke?
A
Carcinogenic and associated with respiratory illnesses in exposed children
Known as secondhand or passive smoke.
12
Q
More than 80% of adult American smokers began smoking before the age of _______.
A
18 years
Counseling of adolescents and young adults is critical to prevent tobacco use.
13
Q
Current approaches to smoking cessation recognize nicotine in tobacco as _______.
A
addicting
The quitting process includes identifiable stages: contemplation, action, and maintenance.
14
Q
Organized cessation programs may help individual efforts, especially for _______ smokers.
A
heavy
These programs may include counseling, behavioral strategies, and pharmacologic adjuncts.
15
Q
The health risks of cigars are similar to those of _______.
A
cigarettes
Smoking one or two cigars daily doubles the risk for oral and esophageal cancers.
16
Q
Chewing tobacco is a carcinogen linked to dental caries, gingivitis, oral leukoplakia, and _______.
A
oral cancer
The systemic effects of smokeless tobacco may increase risks for other cancers.
17
Q
Physical activity is associated with a decreased risk of _______ and breast cancer.
A
colon cancer
Various mechanisms have been proposed, but studies may be prone to confounding factors.
18
Q
International epidemiologic studies suggest that diets high in fat are associated with increased risk for cancers of the _______.
A
- breast
- colon
- prostate
- endometrium
Despite correlations, dietary fat has not been proven to cause cancer.
19
Q
In some observational studies, dietary fiber has been associated with a reduced risk of _______.
A
- colonic polyps
- invasive cancer of the colon
Diet is a highly complex exposure to many nutrients and chemicals.
20
Q
What did the two large prospective cohort studies show regarding fruit and vegetable intake and cancer risk?
A
No association
These studies involved over 100,000 health professionals.
21
Q
What was the outcome of the Polyp Prevention Trial regarding a low-fat, high-fiber diet?
A
No differences in polyp recurrence
The trial involved 2000 elderly persons with polyps removed.
22
Q
The U.S. National Institutes of Health Women’s Health Initiative enrolled over how many women?
A
> 100,000 women
The study focused on women aged 45-69 years.
23
Q
What was the result of the dietary intervention in the Women’s Health Initiative regarding invasive breast cancers?
A
Not reduced
This was observed over an 8-year follow-up period.
24
Q
What is the relationship between body mass index (BMI) and cancer risk?
A
Modest increase in risk beyond 25 kg/m²
Relative risks generally range from 1.0 to 2.0.
25
What type of skin cancers are induced by **cumulative exposure to ultraviolet (UV) radiation**?
Nonmelanoma skin cancers
## Footnote
Includes basal cell and squamous cell cancers.
26
What can reduce the risk of **skin cancer**?
* Protective clothing
* Changing outdoor activity patterns
* Sunscreens
## Footnote
Sunscreens decrease the risk of actinic keratoses but may not reduce melanoma risk.
27
What is **chemoprevention**?
Use of chemical agents to prevent carcinogenesis
## Footnote
It aims to reverse, suppress, or prevent the development of invasive malignancy.
28
What are **initiators** in cancer development?
Factors that cause initial tissue abnormalities
## Footnote
They can be inherited or acquired through carcinogens.
29
List some **suspected carcinogens**.
* Alkylating agents
* Asbestos
* Benzene
* Tobacco
* UV radiation
## Footnote
These agents are linked to various cancers.
30
What is the effect of **cessation of cigarette smoking** on the risk of second malignancies in cured cancer patients?
Does not markedly decrease risk
## Footnote
However, it lowers cancer risk in those who have never developed a malignancy.
31
What is the **field carcinogenesis** hypothesis for upper aerodigestive tract cancer?
It has made 'cured' patients an important population for chemoprevention of second malignancies
## Footnote
This hypothesis suggests that previous cancers may influence the risk of developing new malignancies.
32
Which **HPV type** is particularly associated with an increased risk for cancers of the oropharynx?
HPV-16
## Footnote
This association exists even without other risk factors like smoking or alcohol use.
33
True or false: The use of the **HPV vaccine** is associated with a reduction in oropharyngeal infection rates.
TRUE
## Footnote
It may eventually reduce oropharyngeal cancer rates.
34
What is **oral leukoplakia**?
A premalignant lesion commonly found in smokers
## Footnote
It has been used as an intermediate marker of chemopreventive activity in trials.
35
What was the outcome of the **a-tocopherol/ß-carotene (ATBC) Lung Cancer Prevention Trial**?
* Increased lung cancer incidence and mortality in those receiving ß-carotene
* No effect of a-tocopherol on lung cancer mortality
* Higher incidence of hemorrhagic stroke in a-tocopherol group
## Footnote
Participants were male smokers aged 50-69 years.
36
What did the **-Carotene and Retinol Efficacy Trial (CARET)** demonstrate?
* Harm from ß-carotene
* Lung cancer rate of 6 per 1000 subjects per year for those taking ß-carotene
## Footnote
This trial involved 17,000 American smokers and workers with asbestos exposure.
37
What is the premise behind many colon cancer prevention trials?
Most colorectal cancers develop from adenomatous polyps
## Footnote
Trials use adenoma recurrence or disappearance as a surrogate endpoint.
38
Which drugs are suggested to prevent adenoma formation or cause regression of adenomatous polyps?
* Piroxicam
* Sulindac
* Aspirin
## Footnote
The mechanism of action of NSAIDs is unknown but presumed to work through the cyclooxygenase pathway.
39
What did a meta-analysis of randomized controlled trials find regarding **aspirin**?
Aspirin at doses of at least 75 mg/d resulted in a 33% relative reduction in colorectal cancer incidence after 20 years
## Footnote
No clear increase in efficacy was noted at higher doses.
40
What was the conclusion of the **U.S. Preventive Services Task Force** regarding low-dose aspirin?
Benefits and harms favored initiating low-dose aspirin for colorectal cancer and cardiovascular disease prevention in adults age 50-59 with a 10% or greater 10-year risk of cardiovascular disease
## Footnote
Low-dose aspirin does not appear to benefit the elderly.
41
What did the **Women's Health Initiative** demonstrate about postmenopausal women taking estrogen plus progestin?
They have a 44% lower relative risk of colorectal cancer compared to women taking placebo
## Footnote
The study involved over 16,600 women randomized and followed for a median of 5.6 years.
42
What is **tamoxifen** and its role in breast cancer prevention?
An antiestrogen that decreased the risk of developing breast cancer by 49% in high-risk women
## Footnote
It also reduced bone fractures but had risks of endometrial cancer and thromboembolic events.
43
What did the trial comparing **tamoxifen** with **raloxifene** show?
Raloxifene is comparable to tamoxifen in cancer prevention without the risk of endometrial cancer
## Footnote
Raloxifene had fewer thromboembolic events than tamoxifen.
44
What are **finasteride** and **dutasteride** used for?
5-a-reductase inhibitors that inhibit conversion of testosterone to dihydrotestosterone (DHT)
## Footnote
DHT is a potent stimulator of prostate cell proliferation.
45
What was the outcome of the **Prostate Cancer Prevention Trial (PCPT)**?
Incidence of prostate cancer was 18.4% in the finasteride arm vs 24.4% in the placebo arm
## Footnote
The finasteride group had more patients with tumors of Gleason score 7 and higher.
46
What is the **REDUCE trial** focused on?
Evaluating dutasteride as a preventive agent for prostate cancer
## Footnote
The trial involved ~8200 men with elevated PSA and negative prostate biopsy.
47
What was the **relative risk reduction** in biopsy-detected prostate cancer in the dutasteride arm at 4 years?
23%
## Footnote
This was based on 659 cases in the dutasteride group versus 858 in the placebo group.
48
In the REDUCE trial, what was observed regarding tumors with a **Gleason score of 8 to 10**?
12 tumors in dutasteride arm vs 1 tumor in placebo arm
## Footnote
This difference was statistically significant during years 3 and 4.
49
True or false: The FDA has approved **5-a-reductase inhibitors** for prostate cancer prevention.
FALSE
## Footnote
Detection bias may have influenced findings, but a causative role could not be dismissed.
50
What was the outcome of the **SELECT trial** regarding vitamin E?
Increased risk of developing prostate cancer with vitamin E alone
## Footnote
Hazard ratio was 1.17 compared to placebo.
51
Name the **infectious agents** linked to cancer.
* Hepatitis B
* Hepatitis C
* HPV strains
* Helicobacter pylori
## Footnote
These agents are associated with various cancers, including liver and cervical cancer.
52
What does the **hepatitis B vaccine** prevent?
Hepatitis and hepatomas due to chronic hepatitis B infection
## Footnote
It is effective in reducing the risk of liver cancer.
53
What types of cancers can the **nonavalent HPV vaccine** help prevent?
* Cervical cancer
* Anal cancer
* Genital papillomas
## Footnote
It covers multiple HPV strains and can prevent over 70% of cervical cancers.
54
What is the recommended **dose schedule** for the HPV vaccine in the U.S. for ages 9-14?
Two doses
## Footnote
Teens and young adults aged 15-26 are recommended to receive three doses.
55
What surgical procedure may be considered for women with **severe cervical dysplasia**?
Laser or loop electrosurgical excision or conization
## Footnote
This is a preventive measure against cervical cancer.
56
What is the purpose of **prophylactic bilateral mastectomy**?
Breast cancer prevention in women with genetic predisposition
## Footnote
Studies show significant reduction in breast cancer incidence among those opting for surgery.
57
What is the relative risk reduction for ovarian cancer with **prophylactic salpingo-oophorectomy** in BRCA mutation carriers?
36% relative risk reduction
## Footnote
This procedure is associated with a significant decrease in ovarian or primary peritoneal cancer incidence.
58
What is the goal of **cancer screening**?
Early detection in asymptomatic individuals
## Footnote
Aims to decrease morbidity and mortality from cancer.
59
What are the four indices that describe a screening test's **accuracy**?
* Sensitivity
* Specificity
* Positive predictive value
* Negative predictive value
## Footnote
These indices help evaluate the effectiveness of screening tests.
60
True or false: Screening tests should offer a substantial likelihood of benefit that outweighs harm.
TRUE
## Footnote
This is essential for the justification of screening programs.
61
What are the **four outcomes** of a diagnostic test?
* True positive (a)
* False positive (b)
* False negative (c)
* True negative (d)
## Footnote
These outcomes are used to assess the effectiveness of a diagnostic test.
62
Define **sensitivity** in the context of a diagnostic test.
The proportion of persons with the condition who test positive: a/(a + c)
## Footnote
Sensitivity measures the ability of a test to correctly identify those with the disease.
63
Define **specificity** in the context of a diagnostic test.
The proportion of persons without the condition who test negative: d/(b + d)
## Footnote
Specificity measures the ability of a test to correctly identify those without the disease.
64
What is the **positive predictive value (PPV)**?
The proportion of persons with a positive test who have the condition: a/(a + b)
## Footnote
PPV indicates the likelihood that a positive test result accurately reflects the presence of the disease.
65
What is the **negative predictive value (NPV)**?
The proportion of persons with a negative test who do not have the condition: d/(c + d)
## Footnote
NPV indicates the likelihood that a negative test result accurately reflects the absence of the disease.
66
True or false: **Sensitivity** and **specificity** depend on the prevalence of the disease.
FALSE
## Footnote
Sensitivity and specificity are independent of the underlying prevalence of the disease.
67
What factors determine **positive predictive value (PPV)**?
* Prevalence
* Sensitivity
* Specificity
## Footnote
PPV is influenced by the prevalence of the disease in the population being tested.
68
What is **lead-time bias**?
The patient is diagnosed at an earlier date without influencing the natural history of the disease
## Footnote
This can create an illusion of increased survival without actual life extension.
69
Define **length-biased sampling**.
Occurs when screening tests detect slow-growing, less aggressive cancers more easily than fast-growing ones
## Footnote
This can lead to a skewed understanding of cancer prognosis.
70
What is **selection bias** in screening tests?
The population seeking screening often differs from the general population
## Footnote
This can lead to a healthier cohort being tested, affecting outcomes.
71
What are the **potential drawbacks of screening**?
* Harm from the screening intervention
* Harm from further investigation of positive tests
* Harm from treatment of true positives
## Footnote
These drawbacks can lead to unnecessary treatment and anxiety for patients.
72
What is the strongest evidence to support a **screening test**?
A randomized controlled screening trial with cause-specific mortality as the endpoint
## Footnote
This design helps to offset biases and assess the true effectiveness of screening.
73
What types of cancer screening have potential benefits for certain age groups?
* Cervical cancer
* Colon cancer
* Breast cancer
* Lung cancer (depending on age and smoking history)
## Footnote
Special surveillance may be prudent for high-risk individuals.
74
Which organizations publish **screening guidelines**?
* American Cancer Society (ACS)
* U.S. Preventive Services Task Force (USPSTF)
* American Academy of Family Practitioners (AAFP)
* American College of Physicians (ACP)
## Footnote
These organizations may have varying criteria and recommendations for screening tests.
75
What is the **screening recommendation** for mammography in women aged **40-49 years**?
The decision to start screening should be an individual one
## Footnote
Women who place a higher value on the potential benefit than the potential harms may choose to begin biennial screening between the ages of 40 and 49 years.
76
What is the recommendation for **mammography** in women aged **50-74 years**?
Every 2 years ('B')
## Footnote
This recommendation is based on the balance of benefits and harms of screening.
77
What is the recommendation for **women ≥75 years** regarding mammography?
'I'
## Footnote
This indicates insufficient evidence to make a recommendation.
78
What is the recommendation for **self-examination** in women of all ages?
No specific recommendation
## Footnote
This reflects the lack of evidence supporting its effectiveness.
79
What is the screening recommendation for **women 21-29 years** regarding Pap tests?
Screen with cytology alone every 3 years ('A')
## Footnote
This recommendation is based on the effectiveness of screening in this age group.
80
What is the recommendation for **women 30-65 years** for cervical cancer screening?
* Screen with cytology alone every 3 years
* Co-testing (HPV testing + cytology) every 5 years
## Footnote
Two of three options are recommended for this age group.
81
What is the recommendation for **women >65 years** following adequate negative prior Pap screenings?
'D'
## Footnote
This indicates no further screening is necessary.
82
What is the recommendation for **adults 50-75 years** regarding colorectal cancer screening?
'A' Screen for colorectal cancer
## Footnote
The risks and benefits of the different screening methods vary.
83
What is the recommendation for **adults 76-85 years** regarding colorectal cancer screening?
'C' The decision to screen should be an individual one
## Footnote
This takes into account the patient's overall health and prior screening history.
84
What is the recommended frequency for **colonoscopy** in adults ≥45 years?
Every 10 years
## Footnote
This is a standard recommendation for colorectal cancer screening.
85
What is the recommendation for **fecal occult blood testing (FOBT)**?
Every year
## Footnote
This is recommended for colorectal cancer screening.
86
What is the recommendation for **computed tomography (CT) colonography** in adults ≥45 years?
Every 5 years
## Footnote
This is one of the options for colorectal cancer screening.
87
What is the recommendation for **fecal immunochemical testing (FIT)**?
Every year
## Footnote
This is another method for colorectal cancer screening.
88
What is the **recommended screening test** for **lung cancer** in adults aged 55-80 with a ≥30 pack-year smoking history?
Low-dose CT scan
## Footnote
Recommended by USPSTF with a grade of 'B'. Discontinue after 15 years of not smoking or if health problems arise.
89
For women at high risk of **ovarian cancer**, what is the recommendation regarding **transvaginal ultrasound** and **CA-125** testing?
No proven benefit in reducing mortality
## Footnote
Currently, there are no reliable screening tests for early detection of ovarian cancer.
90
What is the **USPSTF recommendation** for **prostate-specific antigen (PSA)** screening in men aged 55-69?
Individual decision-making
## Footnote
Men should discuss potential benefits and harms with their clinician.
91
What is the **USPSTF recommendation** for **men aged 70 years and older** regarding PSA screening?
'D' - recommend against screening
## Footnote
There is moderate or high certainty that the service has no net benefit.
92
What is the **recommendation** for **digital rectal examination (DRE)** in conjunction with PSA testing?
No individual recommendation
## Footnote
If men decide to be tested, they should have the PSA blood test with or without a rectal exam.
93
What is the **USPSTF recommendation** for a **complete skin examination** by a clinician for adults?
'I' - no guidelines
## Footnote
There are currently no recommendations for skin examination.
94
What is the **impact of mammography** on breast cancer mortality for women older than 50 years?
Decreases mortality by 15-30%
## Footnote
This is based on various trials, though design flaws have been noted.
95
What was the finding of the **U.K. Age Trial** regarding mammography in women aged 40-49?
No statistically significant difference in mortality
## Footnote
The trial showed a relative risk of 0.83, but <70% of women received screening.
96
What is the **relative reduction in mortality** from mammography screening for women aged 39-49 years?
8% relative reduction
## Footnote
This is based on a meta-analysis of nine large randomized trials.
97
What is the **concern regarding overdiagnosis** in breast cancer screening?
Ranges from 10 to 50% of diagnosed invasive cancers
## Footnote
Despite increased early-stage disease, there has not been a reduction in metastatic breast cancer incidence.
98
What is **digital breast tomosynthesis**?
A newer method of breast cancer screening
## Footnote
It reconstructs multiple x-ray images into three-dimensional slices, but health outcome data is lacking.
99
What is the **recommendation for genetic screening** for BRCA1 and BRCA2 mutations?
Identify high-risk women, but timing and frequency are undefined
## Footnote
Mammography may be less sensitive for these women.
100
What is the effect of **Papanicolaou (Pap) smears** on cervical cancer mortality?
Decreases cervical cancer mortality
## Footnote
The mortality rate has fallen substantially since the widespread use of Pap smears.
101
What is the **fundamental etiologic factor** for cervical cancer?
HPV
## Footnote
HPV is a significant risk factor associated with the onset of sexual activity.
102
What is the recommended interval for **Pap screening** for women who have reached the age of 21?
3 years
## Footnote
Screening more frequently adds little benefit but can lead to important harms.
103
True or false: Screening for cervical cancer should begin before the age of 21, even in individuals that have begun sexual activity.
FALSE
## Footnote
Screening before age 21 may cause more harm than benefit.
104
What is the sensitivity of **CT colonography** for polyps ≥6 mm compared to colonoscopy?
Comparable
## Footnote
CT colonography, if done at expert centers, has a high sensitivity for detecting polyps.
105
What is a concern associated with **repeated colonography screenings**?
* Extracolonic findings
* Long-term cumulative radiation risk
## Footnote
The rate of abnormalities of uncertain significance is high (~5-37%).
106
What did the **National Lung Screening Trial (NLST)** demonstrate regarding lung cancer screening?
Statistically significant reduction in deaths
## Footnote
The trial showed about 3 fewer deaths per 1000 people screened with CT compared to chest x-ray.
107
What is the relative risk of dying from lung cancer when comparing annual chest x-ray to usual care according to the NLST?
0.99
## Footnote
This indicates no significant reduction in lung cancer mortality.
108
What are the three modalities considered for **ovarian cancer screening**?
* Adnexal palpation
* Transvaginal ultrasound (TVUS)
* Serum CA-125 assay
## Footnote
A large trial showed that annual screening does not reduce deaths from ovarian cancer.
109
What is the **false-positive rate** of the **Fecal Occult Blood Testing (FOBT)** for colorectal cancer?
High
## Footnote
The high false-positive rate increases the number of unnecessary colonoscopies.
110
What is the **most common prostate cancer screening modality**?
* Digital rectal exam (DRE)
* Serum PSA assay
## Footnote
PSA screening has led to prostate cancer becoming the most common nonskin cancer diagnosed in American males.
111
What is the recommended screening interval for **sigmoidoscopy**?
5 years
## Footnote
The most efficient interval for screening sigmoidoscopy is still unknown.
112
What is the **relative reduction** in colorectal cancer mortality after biennial FOBT according to a meta-analysis?
22%
## Footnote
This reduction is observed after two to nine rounds of screening over 30 years.
113
What is the **sensitivity** of **Fecal Immunochemical Tests (FITs)** compared to FOBT?
Higher
## Footnote
FITs have shown higher sensitivity for colorectal cancer detection.
114
What is the **risk associated** with the high number of false-positive results in ovarian cancer screening?
Increased follow-up colonoscopies
## Footnote
The ratio of surgeries to screen-detected ovarian cancer was approximately 20:1.
115
What is the **recommended action** if adenomatous polyps are diagnosed by sigmoidoscopy?
Evaluate the entire colon with colonoscopy
## Footnote
This is crucial for comprehensive assessment.
116
What is the **relative risk** of death from ovarian cancer in women undergoing annual screening with TVUS and CA-125?
1.21
## Footnote
This indicates no statistically significant reduction in ovarian cancer deaths.
117
What were the two major **randomized controlled trials** of PSA screening on prostate cancer mortality?
* PLCO Cancer Screening Trial
* European Randomized Study of Screening for Prostate Cancer (ERSPC)
## Footnote
These trials aimed to evaluate the effectiveness of PSA screening in reducing prostate cancer deaths.
118
In the **PLCO Cancer Screening Trial**, how many men were randomized?
Almost 77,000 men
## Footnote
The trial involved men aged 55-74 years.
119
What was the follow-up duration for the **PLCO Cancer Screening Trial**?
13 years
## Footnote
No statistically significant difference in prostate cancer deaths was noted between the arms.
120
What was the rate ratio for prostate cancer deaths in the **PLCO Cancer Screening Trial**?
1.09 (95% confidence interval 0.87-1.36)
## Footnote
This indicates no significant difference in mortality between the screening and control groups.
121
In the **ERSPC**, how many men were randomized?
Approximately 182,000 men
## Footnote
The trial focused on men aged 50-74 years, with a core group of 55-69 years.
122
What was the median follow-up duration for the **ERSPC**?
15.5 years
## Footnote
A 20% relative reduction in the risk of prostate cancer death was noted in the screened arm.
123
How many men need to be invited to screening to avert **1 death from prostate cancer** according to the ERSPC?
570 men
## Footnote
This statistic highlights the number of screenings required to prevent one death.
124
What was the prostate cancer-specific survival rate at a median follow-up of **10 years**?
About 99%
## Footnote
This rate was nearly identical between treatment groups.
125
What are some potential morbidities caused by treatments for low-stage prostate cancer?
* Impotence
* Urinary incontinence
## Footnote
These side effects can significantly impact the quality of life.
126
What is the method used for screening **skin cancer**?
Visual examination of all skin surfaces
## Footnote
This can be performed by the patient or a health care provider.
127
True or false: There has been a prospective randomized study showing a mortality decrease from skin cancer screening.
FALSE
## Footnote
Screening for skin cancer has not been shown to decrease mortality and is associated with overdiagnosis.
128
What types of skin cancers are screened through visual examination?
* Basal cell cancers
* Squamous cell cancers
* Melanoma
## Footnote
These are the primary types of skin cancer targeted in screening efforts.
RITE
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