1
Q
Overall most common cancer in US?
A
- basal cell and squamou skin cancer
2
Q
Most common cancers in men and women after skin cancer?
A
- prostate
- breast
3
Q
Most common cause of cancer death?
A
- lung and bronchus: both males and females
4
Q
How can cancer be prevented?
A
it’s all about lifestyle:
- avoid tobacco
- be physically active
- maintain a healthy wt
- limit alcohol
- avoid excess sun
- eat a diet rich in fruits, veggies, and whole grains, and low in saturated/trans fat
- protect against STIs
- get regular screening for breast, cervical and CRC
5
Q
Main principles of screening?
A
Screening is indicated when:
- disease has high prevalence
- disease has serious consequences
- has detectable preclinical phase
- tx for presx disease is more effective than after sx development
- positive impact on clinical health outcomes
- other considerations:
what are pt’s co-morbid conditions? Assoc life expectancy, feasibility of tx, effects of tx on quality of life?
What will you do with the results?
6
Q
What cancers are largely asx in early stages? What is their 5 yr survival rate?
A
- CRC, breast, and cervical cancer are each largerly asx in early stages
- they have at least a 90% 5 yr survival rate if detected and tx when the cancer is still localized
7
Q
Leading cause of death from a gyn malignancy in US?
A
- ovarian cancer
- survival is much improved for earlier stage disease, however most cancers have spread beyond ovary at time of dx
8
Q
Do annual pelvic exams reduce mortality from ovarian cancer?
A
- no evidence that supports this
- ovarian tumors can be detected during bimanual pelvic exam, although early stage tumors are rarely found due to deep anatomic location of ovary
- tumors detected by bimanual pelvic exam are usually at an advanced stage and assoc with poor prognosis
9
Q
Has screening with annual CA 125 and TVUS in postmenopausal women been beneficial? Which women should be screened for these? When should this screening be started?
A
- screening with these tumor markers have shown no decrease in mortality from ovarian cancer
- women with a familial ovarian cancer syndrome or BRCA genes, who haven’t undergone prophylactic oophorectomy, should be screened with combo of CA 125 and TVUS
- initiation at 35 or 5-10 yrs earlier than earliest age of 1st dx of cancer in family
10
Q
What are the BRCA mutations? Assoc cancer risks?
A
- 1 and 2: inherited as auto dominant, highly penetrant, germline mutations that are assoc with inherited susceptibility to breast and ovarian cancer
- BRCA 1 carriers:
cumulative risk by 70 -
breast cancer: 60%
ovarian: 59%
contralateral breast: 83% - BRCA 2 carriers: cum risk by 70-
breast cancer: 55%
ovarian: 16.5%
contralateral breast: 62%
11
Q
Ovarian cancer screening recommendations?
A
- USPSTF and CS recommend against it
- ACS recommends annual pelvic exam in pts 21 and older
- this doesn’t include women with known BRCA mutations
12
Q
Does screening for ovarian cancer have a positve impact on clinical health outcomes?
A
- no - annual pelvic exams, CA-125, and TVUS don’t decrease mortality from ovarian cancer
13
Q
How can ovarian cancer be prevented?
A
- oral contraceptives (50% less chance of ovarian cancer if on OCPs for more than 5 yrs)
- gyn surgery
- pregnancy
- breastfeeding
14
Q
Main reason for decrease in rates of cervical cancer?
A
- it was once one of the MCCx of cancer death for American women
- over last 30 yrs death rate has gone down by more than 50%
- main reason for this is increased use of pap test. The screening procedure can find changes in cervix b/f cancer develops. It can also find cervical cancer early in its most curable stage
15
Q
Cervical cancer screening recommendations?
A
- USPSTF, ACS, and ACOG recommend:
all women shoul begin cervical cancer screening at 21 unless they have HIV or are immunocompromised - from 21-29 cytology only q 3 yrs
- beginning at 30:
cytology q 3 yrs and co-testing cytology and HPV testing q 5 yrs - may stop after 65 if adequate screening in past 10 yrs w/ 2 negative screens, if not getting adequate screening wait until 70-75
16
Q
What are high risk groups for cervical cancer?
A
those who need more frequent screening (usually annually):
- pts with HIV infection
- pts who are immunocompromised (SLE)
- those who had in utero DES exposure
- women have been tx for CIN2, CIN3, or cervical cancer
17
Q
What women who have had total hysterectomy should continue to have pap tests done?
A
- if they had surgery for tx of cervical cancer or pre-cancer
- women who had hysterectomy w/o removal of the cervix should continue to have pap tests
- women who had their cervix out for reasons other than cervical cancer DON’T need pap smears
18
Q
Cervical cancer prevention?
A
- Gardasil
- avoid exposure to HPV (use protection)
- pap smear: detects pre-cancerous changes before it becoems invasive cancer
19
Q
How common is breast cancer in US? Mortality? Primary risk factors? When are majority of cancers dx?
A
- 2nd MC cancer in women, 1/8 women in US will develop invasive breast cancer during their lifetime
- 2nd leading cause of cancer death in woemn
- primary RFs: gender - predom. females, age: about 85% of breast cancers occur after women reach 50
- majority of cancers are dx as a result of an abnormal screening study
20
Q
Breast cancer survival rates by stage?
A
- 100%: stage 1
- 93%: II
- 72%: III
- 22%: IV
21
Q
Screening tools for breast cancer detection?
A
- mammography remains the mainstay
- US is usually used to f/u abnormalities on mammogram
- MRI is emerging for screening high risk pts in combo with mammography
22
Q
Breaset cancer mammography screening recommendations?
A
- ACOG recommends annual mammogram after age 40
- ACS recommends q year age 45-49
- USPTSF recommends them q 2 years starting 50-54
- life expectancy of less than 10 yrs: ACS no longer recommends regular mammograms if woman has illness or condition that gives her a life expectancy less than 10 yrs
23
Q
Breast cancer CBE screening recommendations?
A
- ACOG: CBE be performed annually in women aged 40 and up, CBE for women 21 q 1-3 yrs
- ACS doesn’t recommend CBE and SBE
- USPSTF: recommends against teaching SBE, states evidence is insufficient to assess additional benefits and harms of CBE
- all 3 organizations recommend pt breast self awareness and that women report changes in their breasts to their providers
24
Q
Proper CBE?
A
- flatten breast tissue against chest
- examine in vertical strips
- maek circular motions w/ pads of middle 3 fingers
- examine each breast w/ 3 diff pressures for at least 3 minutes
25
When should mammography screening be stopped?
- some recommend 70-75
- insufficient data and studies to determine if any benefit vs risks
- it depends, q pt is diff.
- other groups suggest that as long as a woman has a life expectancy of at least 10 yrs breast cancer screening with mammogram may be continued
26
How common is CRC in US?
- 3rd MC cancer dx in US
- overally, lifetime risk of developing CRC is 1/20 (5%)
- CRC is 2nd leading cause of cancer related deaths in US
27
How can you assess risk of CRC?
ask the following ?s:
- starting at 20 and q 5 yrs thereafter
- have you ever had CRC or an adenomatous polyp?
- have you ever had IBD?
- have any family members had CRC or an adenomatous polyp? If so, how many, were they 1st degree relatives and at what age was the cancer or polyp dx?
- if there is one yes answer - pt may be at risk and needs further eval
28
USPSTF, ACS recommendations for CRC screening?
- avg risk men and women 50-75
- FOBT (with a sensitive test): annually beginning at 50
- flex sigmoidoscopy: q 5 yrs, beginning at 50, + sensitive FOBT q 3 yrs
- colonoscopy: q 10 yrs, beginning at 50
- virtual colonoscopy q 5 yrs
29
Pros and Cons of FOBT?
- finds blood in stool (need 3 samples):
stool guaiac (low sensitivity)
immunochemical stool tests (increased sensitivity, w/o loss of specificity)
- a FOBT may be done to check for some intestinal conditions or CRC
- + FOBT always warrants a colonoscopy
- blood in stool may be the only sx of CRC, but not all blood in stool is caused by cancer
30
Pros and Cons of sigmoidoscopy?
- thin, flexible sigmoidoscope is inserted into the rectum
- tiny camera at tip of tube allows one to view inside of rectum and most of sigmoid and about last 2 feet of large intestine
- bx can be taken through the scope during a flex sig exam
- poses few risks:
bleeding from site where tissue sample taken, a tear in colon or rectum wall
- drawbacks: can't see entire colon, proximal lesions may not be seen
31
Pros and cons of colonoscopy?
- endoscopic exam of colon and distal part of small bowel with fiber optic camera on a flexible tube passed through the rectum
- it may provide a visual dx (ulceration, polyps), and allows the opportunity for bx or removal of suscpected lesions
- complications:
bleeding from site where bx was taken, tear in colon or rectum wall
32
What is the CDC colorectal cancer control program?
- free or low cost screening:
provide funding in 26 states and tribes across US
- program supports population based screening efforts and provides CRC screening services to low income men and women 50-64 who are underinsured or unisured for screening, when no other insurance is available
- in addition to screening, program sites also provide dx f/u
33
Screening for high risk CRC pops?
- 1st degree relative with colon CA or adenomatous polpy dx younger than 60 or 2 1st degree relatives with colon CA at any age: screening colonoscopy at 40 or 10 yrs prior to earliest family dx, repeat screen q 5 yrs
- FAP: annual sig starting 10-12
- HNPCC: colonoscopy q 1-2 yrs beginngin age 20-25 or 10 yrs prior to earliest CA dx in family
- hx of adenomatous polyp: surveillance based on pathology and number of adenomas at most recent prior colonoscopy
any adenoma with high grade dysphasia or villous features, or multiple adenoma (3 or more) - repeat in 3 yrs
1-2 small (under 1 cm) tubular adenomas with low grade dysplasia only: repeat colonoscopy in 5 yrs
34
What is a virtual colonoscopy?
- CT colonography - test that uses a CT scanner to take images of entire bowel. These images are in 2 and 3D, and are reconstructed to allow a radiologist to determine polyps or cancers present
- major advantages: doesn't reqr sedation, non-invasive, entire bowel can be examined, abnormal areas (adenomas) can be detected about as well as traditional (optical) colonoscopy
- BUT: if abnormality detected then the pt must have a colonoscopy to obtain tissue or remove a polyp
35
How common is prostate cancer?
- 2nd MC cancer in men
- about 1/7 men will be dx with prostate cancer during his lifetime
- occurs mainly in older men, about 60% of cases are 65 and older, rare b/f 40. Avg age at time of dx: 66
- 2nd leading cause of cancer death, behind only lung cance
- 1/38 men will die of prostate cancer
36
Screening tests for prostate cancer?
- DRE
| - PSA
37
Usefulness of DRE?
- can detect tumors in posterior and lateral aspects of prostate - only 85% of tumors are peripheral
- can't detect those that aren't peripheral
- a negative exam doesn't change likelihood of clinically sig prostate cancer: no controlled studies have shown a reduction in morbidity or mortality of prostate CA when detected by DRE at any age
38
Test issues of PSA screening?
- levels of 4 ng/ml or less have typically been considered to be normal
- results from prostate cancer prevention trial show that prostate cancer is not rare even in these men:
27% cancer with PSA 3.1-4
24% 2.1-3
17% 1.1-2
10% 0.6-1
7% 0-0.5
- positive predictive value: for PSA 4-10 ng/ml 25% of men will have prostate cancer - nearly 75% of cancers detected in this gray zone are organ confined and potentially curable, there is a high false positive rate which leads to many unnecessary bx
- for PSA greater than 10 - 42-64% will have prostate CA
- recommended that men be given info on pros and cons of screening b/f making their own screening decisions (what are you going to do with the results?)
39
Potential benefits of prostate screening?
- screening can detect cancers early
- tx for prostate CA is more effective when found early
- 5 yr survival in men with localized prostate cancer or just regional spread is 100% compared with 32% in those with distant mets
40
Postential risks of prostate screening?
- false + test results that lead to further tests and can cause anxiety ($$, and invasive)
- potential SEs: infection from bx
- tx of some prostate CA that may have never affected a man's health even if left untx
41
Prostate cancer screening recommendations?
- USPSTF: recommends against PSA based screening
- ACS: men should have chance to make informed decision with their health care provider about whether to be screened for cancer
- AUA: doesn't recommend screening in men b/t 40-54 at avg risk, for men younger than 55 at higher risk (African american or + family hx) - screening should be individualized, strongly recommend shared decision making for men 55-69 that are considered PSA screening, and proceeding based on values and preferences of the pt
- greatest benefit of screening appears to be 55-69
42
Should we screen for Prostate CA?
- disease has a high prevalence: 2nd most common dx CA in US men
- detectable preclinical phase: PSA and DRE maybe
- complications of CA tx: sexual dysfxn, urinary incontinence, bowel dysfxn
- does screening reduce mortality: screening with PSA with or w/o DRE compared to no screening didn't reduce death from prostate cancer
- screening sig increased prostate CA dx (over dx?)
- risk reduction in mortality from regular screening all men with PSA testing is very small
- impt concerns: harms of tx to quality of life, substantial risk of overdx
- men who are at higher risk (African Americans and family hx) may be more likely to benefit
- for most men it is impt that they make an informed decision about undergoing PSA testing
43
If pt decides they want to be screened - when should it start?
- in most men discussion should begin at 50: unless they have comorbidity and life expectancy is less than 10 yrs, PSA level can be checked q 2-4 yrs
- screening may be discussed at 40 for:
African American men
men with family hx of prostate cancer, esp in relatives younger than 65, men who are known to have BRCA 1 or 2 mutation
- stop screening when man has less than 10 yr life expectancy
44
Recommendations for lung cancer screening?
USPSTF, ACS:
- recommends annual screening for lung cancer with low dose CT in adults 55-80 who have 30 pack yr smoking hx and currently smoke or have quit within the past 15 yrs
- screening should be d/c once a person has not smoked for 15 yrs or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery
45
Screening guidelines for people at high risk for lung cancer - ACS?
- 55-74 yrs of age
- in fairly good health
- have at least 30 yr pack hx and are still smoking or have quit w/in last 15 yrs
recommend screening:
- method - LDCT scan
- location: center that can accurately do the scans and have expertise to interpret and advise the patient
- risk: unnecessary bxs and even partial removal of the lung
46
What was the national lung screening trial?
- large, randomized controlled trial
- 33 ntl cancer institutions
- 53,000 current/former smokers
55-74 yrs old
30 pack yr or more hx
quit less than 15 yrs ago
- randomized CXR vs LDCT
- results: 20% relative reduction in lung cancer mortality with screening LDCT
- found to be cost effective (11-26K per life saved, mammogram = 31-51 k
- individuals needed to screen to save one life - 320 compared to mammogram -800
-downside: 20% false positive rate, 2% suffered complications
47
Principles of screening for lung cancer?
- disease has high prevalence: 2nd most common cancer in US
- disease has serious consequences: #1 cause of cancer mortality for both mena and women
- detectable preclinical phase: LDCT annually in high risk pts successfully detects earlier stages
- tx for pre-symptomatic disease is more effective than after sxs develop: when detected in stage 1 - improves 5 yr survival from 15% to 40-70%
- screening does reduce cancer mortality (LDCT -20% decrease in mortality)
48
Prevention of lung cancer can be accomplished by?
- smoking cessation
- lung cancer incidence rates have stabilized in women and are declining in men in the US
- true across race-ethnicities
49
How common is skin cancer? Prevention?
- MC of all cancers!!!!
| - wear sunscreen, don't use tanning beds
50
Effectiveness of screening for skin cancer depends on what factors?
- whether the clinician performing the exam can ID early staging disease
- whether the pathologist can accurately dx and histologically stage the disease
- whether the tumor is ID at a stage where tx would be effective
- whether the tumor ID by screening would become cliinically meaningful to the pt in his or her lifetime. ID a disease that wouldn't impact a person's quality or duration of life is referred to as "overdx"
51
How common are oral cancers?
- more than 2x as common in men as in women. Equally common in blacks and whites
- In recent years - overall rate of new cases of this disease has been stable in men and dropping slightly in women. However there has been recent rise in case of oropharyngeal cancer linked to infection with HPV in white men and women
- avg age of most people dx with these cancers is 62, but they can occur in young people
52
Oral Cancer screening recommendations?
ACS:
- regular dental checkups that include an exam of the entire mouth are impt in finding oral and oropharnygeal cancers (and pre-cancers) early. The ACS also recommends that doctors examine the mouth and throat as part of a routine cancer-related check-up
