early detection: screening guidelines · computerized tomographic colonography) — in this test,...
TRANSCRIPT
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Early Detection: Screening Guidelines
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National Cancer Statistics
Over 13.7 million people are living with and surviving cancer today.
2015 National Cancer Statistics
• 1. 6 Million Cases Expected
• 589,430 Cancer Deaths expected
2015 Virginia Cancer Statistics:
• Projected cases: 41,170
• Projected deaths: 14, 830
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2015 Virginia Cancer Estimations for Cancer Sites with ACS
Screening Guidelines
Breast 6,090
Cervical 320
Colorectal 2,970 Lung 5,470
Prostate 6,120
Melanoma
2,230
These 6 cancer sites account for 56% of all newly
diagnosed cancers in Virginia
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Breast Cancer Breast cancer is a malignant (cancerous) tumor that develops from cells in the breast.
The most common cancer among
women in Virginia, and the second deadliest
6,090
1,820 -
2,000
4,000
6,000
8,000
10,000
Diagnosed (new) Deaths
2015 Breast Cancer in Virginia(Estimations)
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5-Yr Survival Rate by Stage of Diagnosis
Source: Howlader N, Noone AM, Krapcho M, Neyman N, Aminou R, Altekruse SF, Kosary CL, Ruhl J, Tatalovich Z, Cho H, Mariotto A, Eisner MP, Lewis DR, Chen HS, Feuer EJ, Cronin KA (eds). SEER Cancer Statistics Review, 1975-2009 (Vintage 2009 Populations), National Cancer Institute. Bethesda, MD, http://seer.cancer.gov/csr/1975_2009_pops09/, based on November 2011 SEER data submission, posted to the SEER web site, 2012
60%33%
5%
2%
% Found at each stage
89.0
98.4
83.9
23.8
50.7
0.0
20.0
40.0
60.0
80.0
100.0
120.0
All Stages Localized Regional Distant Unstaged
Perc
enta
ge
Breast Cancer 5-Year Survival Rate
by Stage at Diagnosis (2002-2008)
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ACS screening recommendations
1. Mammography
2. Clinical Breast Exam
3. Breast Self-Awareness
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1. Mammogram
Recommendation:
Yearly Mammogram Starting at Age 40
Women at High Risk Should Talk With
Their Doctor
Concerns:
1. Overdiagnosis and resulting treatment of insignificant cancers
2. False-positives with additional testing and anxiety
3. Radiation-induced breast cancer
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2. Clinical Breast Exam
A healthcare provider examines a woman’s
breasts
Recommendation:
• Age 20’s & 30’s – Clinical breast exam
every three years
• Age 40 + - Clinical breast Exam every year
Concerns:
1. False-positives with additional testing and anxiety
2. False-negatives with potential false reassurance and delay in cancer
diagnosis
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3. Breast Self-Awareness
Women need to know how their breasts
normally look and feel and report changes to
their doctor right away
Recommendation: Breast Self-Exam Is An Option Starting in the 20’s
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Other screening options
Screening Modalities:
• Digital Mammography
• MRI
• Ultrasound
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Digital Mammography
• Overall, similar accuracy as film mammography
• Somewhat better sensitivity for women under 50, pre- and peri-menopausal
women, and women with dense breasts
• Trend toward lower sensitivity for women over 65
• Practical and logistical advantages, e.g. storage and transfer of images
• Available in ~20% of US facilities
• Higher cost
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MRI
Cons
High false positive rate of MRI makes it inappropriate for screening women at average risk
Insufficient evidence to recommend for or against MRI screening of women at moderately increased risk based on clinical factors such as density
Insufficient evidence for other technologies
Pros
Ability of MRI to detect cancers is much higher (double) than mammography
MRI plus mammography detects more cancers than MRI alone
Strong evidence for MRI screening of women at increased risk based on family history/genetics
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Ultrasound • Useful for diagnostic imaging
• Not recommended for screening
• Less sensitive than MRI
• May be more sensitive than mammography, especially for
dense breasts, but high false-positive rate
Breast Biopsy • Fine needle aspiration (FNA) biopsy
• Core needle biopsy
• Surgical (open) biopsy
• Biopsy accuracy
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BRCA testing
• Rare genetic variations, known as mutations, found in less than 1% of the
general population.
• The most common of these mutations are located in two genes
named breast cancer gene 1 and breast cancer gene 2 (BRCA1 and
BRCA2).
• ACS encourages women to speak to a doctor about gene testing if …
• Two or more first-degree relatives (mother, sister, daughter) who have
had breast cancer
• First-degree relative had her cancer before age 50, or in both breasts
• Family history of other cancers, such as ovarian cancer, might also
lead to an increased risk of breast cancer
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Colorectal Cancer
Different types of polyps:
Hyperplastic
minimal cancer potential
Adenomatous
approximately 90% of colon and rectal
cancers arise from adenomas
Most cases of colon cancer start from a non-cancerous growth in the
colon (a polyp)
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Normal to Adenoma to Carcinoma
Human colon carcinogenesis progresses by the dysplasia/adenoma to carcinoma pathway
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5-Yr Relative Survival Rate
89.9
69.6
11.9
33.9
0102030405060708090
1005-
yr S
urvi
val (
%)
Stage of Detection
Survival Rates by Disease Stage*
*2002- 2008
39%
36%
20%
5%
% Found at each Stage
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Two categories of screening
1. Tests that detect cancer and precancerous polyps
It is the strong opinion of the consensus guidelines group that colon cancer prevention should be the primary goal of CRC screening.
• Exams that are designed to detect both early cancer and
precancerous polyps should be encouraged if resources are available
and patients are willing to undergo an invasive test
• If the full range of screening tests are not available, physicians
should make every effort to offer at least one test from each
category
2. Tests that primarily detect cancer
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Colon Cancer Screening Tests
When to start?
Regular colon testing should begin at age 50. Individuals with a family history
should begin screening earlier.
Tests That Detect Adenomatous Polyps and Cancer
Flexible sigmoidoscopy (FSIG) every 5 years, or
Colonoscopy every 10 years, or
Double contrast barium enema (DCBE) every 5 years, or
CT colonography (virtual colonoscopy) every 5 years
Tests That Primarily Detect Cancer
Annual fecal occult blood test (FOBT) every year or
Annual fecal immunochemical test (FIT) or
Stool DNA test (sDNA), - this test is no longer available.
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Fecal occult blood test (FOBT)
This test checks for hidden blood in fecal
material (stool). Currently, two types of FOBT
are available.
Sigmoidoscopy—In this test, the rectum and lower colon are
examined using a lighted instrument called sigmoidoscope.
During sigmoidoscopy, precancerous and cancerous growths in
the rectum and lower colon can be found and either removed
or biopsied.
Colonoscopy—In this test, the rectum and entire colon are
examined using a lighted instrument called a colonoscope. Unlike
sigmoidoscopy growths in the upper part of the colon can be
removed.
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Double contrast barium enema (DCBE)—In this test, a
series of x-rays of the entire colon and rectum are taken
after the patient is given an enema with a barium
solution and air is introduced into the colon. The barium
and air help to outline the colon and rectum on the x-
rays.
Virtual colonoscopy (also called
computerized tomographic colonography)—
In this test, special x-ray equipment is used
to produce pictures of the colon and rectum.
A computer then assembles these pictures
into detailed images that can show polyps
and other abnormalities.
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Emphasis on options
Options are emphasized because…
1. Evidence does not yet support any single test as “best”
2. Uptake of screening remains disappointingly low
3. Individuals differ in their preferences for one test or another
4. Primary care physicians differ in their ability to offer, explain, or refer patients to all options equally
5. Access is uneven geographically, and in terms of test charges and insurance coverage
6. Uncertainty exists about performance of different screening methods with regard to benefits, harms, and costs (especially on programmatic basis)
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If tests that can prevent CRC are preferred, why not recommend
them alone?
Greater patient requirements for successful completion
Endoscopic and radiologic exams require a bowel prep and an office or facility visit
No true “gold standard”
Colonoscopy misses 5 – 10% of significant lesions in expert settings
Higher potential for patient injury than fecal testing
Risk levels vary between tests, facilities, practitioners
Patient preference
Many individuals don’t want an invasive test or a test that requires a bowel prep
Some prefer to have screening in the privacy of their home
Some may not have access to the invasive tests due to lack of coverage or local resources
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• Lung cancer is the leading cause of cancer –related deaths for men and women.
• In 2015
• 5,470 people will be diagnosed with lung cancer in Virginia
• 4,070 will die of this disease
Lung Cancer
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Survival Rates
15.9
52.2
25.1
3.7
7.9
0
10
20
30
40
50
60
All Stages Localized Regional Distant Unstaged
Perc
enta
ge
Lung Cancer 5-Year Survival Rate
by Stage at Diagnosis (2002-2008)
15%
22%
57%
6%
% Found at each Stage
Source: Howlader N, Noone AM, Krapcho M, Neyman N, Aminou R, Altekruse SF, Kosary CL, Ruhl J, Tatalovich Z, Cho H, Mariotto A, Eisner MP, Lewis
DR, Chen HS, Feuer EJ, Cronin KA (eds). SEER Cancer Statistics Review, 1975-2009 (Vintage 2009 Populations), National Cancer Institute. Bethesda, MD,
http://seer.cancer.gov/ csr/1975_2009_pops09/, based on November 2011 SEER data submission, posted to the SEER web site, 2012
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Who should having screening…
ACS recommends that doctors speak to patients at high risk for
developing lung cancer
Patients should meet specific criteria:
• Ages 55-74 years
• Fairly good health
• Heavy smoking history (approx. a pack per day for 30 years)
• Currently smoke or quit within the past 15 years
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Screening
• For patients at high risk…
Low-dose CT scan (LDCT)
Benefit:
• On average, for every 5 people at high risk for lung cancer, getting this test every
year can prevent one person from dying of lung cancer
Concerns:
• LDCT will not find all lung cancers or all lung cancers early, and not all patients who have a lung cancer diagnosed by LDCT will avoid death from lung cancer
• There is a chance of a false-positive result and may require more testing, and an
invasive procedure (like removing a sample of lung tissue) might need to be done
Source: Unknown. (2013). Testing for Lung Cancer in People at High Risk. CA, 63 (2).
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Prostate Cancer
Prostate cancer is the most frequently diagnosed cancer
in men other than skin cancer.
6,120
6700
2,000
4,000
6,000
8,000
10,000
12,000
Diagnosed (new) Deaths
Prostate Cancer in Virginia, 2015(Estimations)
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Survival Rates
99.2 100 100
27.8
71.1
0
20
40
60
80
100
120
All Stages Localized Regional Distant Unstaged
Perc
enta
ge
Prostate Cancer 5-Year Survival Rate
by Stage at Diagnosis (2002-2008)
Source: Howlader N, Noone AM, Krapcho M, Neyman N, Aminou R, Altekruse SF, Kosary CL, Ruhl J, Tatalovich Z, Cho H, Mariotto A, Eisner MP,
Lewis DR, Chen HS, Feuer EJ, Cronin KA (eds). SEER Cancer Statistics Review, 1975-2009 (Vintage 2009 Populations), National Cancer Institute.
Bethesda, MD, http://seer.cancer.gov/ csr/1975_2009_pops09/, based on November 2011 SEER data submission, posted to the SEER web site, 2012.
81%
12%
4% 3%
% Found at each Stage
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Early Detection of Prostate Cancer .
There are two main screening tests for prostate cancer.
Test #1: PSA blood test (Prostate Specific Antigen)
• Measures protein made by prostate cells
• Newer PSA tests:
• Percent-free PSA (fPSA)
• Complexed PSA
Note: High PSA levels in blood do not always mean there is
cancer
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Factors other than prostate cancer that may affect PSA levels…
Elevate levels
• Enlarged Prostate
• Old age
• Prostatitis
• Ejaculation
• Riding a bike
• Certain urologic procedures &
medicines
Lower levels
• Certain medicines
• Herbal mixtures
• Obesity
• Aspirin
Overall levels: Age, Race, Family History
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Digital Rectal Exam (DRE)
Test #2: DRE
• Doctor inserts a gloved, lubricated finger into the rectum to feel for any
bumps or hard areas on the prostate that might be cancer.
• DRE is less effective than the PSA blood, but it can sometimes find
cancers in men with normal PSA levels.
• The DRE is also used once a man is known to have prostate cancer. It
can help tell whether the cancer has spread beyond his prostate gland. It
can also be used to find cancer that has come back after treatment.
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Benefits & Concerns about Screening
Benefits:
• The evidence is insufficient to determine whether screening reduces mortality
• Detection at an early stage, but it is not clear whether earlier detection and
consequent earlier treatment leads to any change in the natural history and
outcome of the disease
Concerns:
• Overtreatment - screening with PSA and/or DRE detects some prostate cancers
that would never have caused important clinical problems
• Side effects - May result in permanent side effects in many men such as erectile
dysfunction and urinary incontinence.
• Prostatic biopsies - associated with complications, including fever, pain,
hematospermia/hematuria, positive urine cultures, and rarely sepsis.
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ACS Screening Recommendations
• Men 50 years and older should discuss the potential benefits and limitations of screening tests and
treatments with their doctors, and make an informed
decision.
• Men at increased risk (such as African American
men and men with a first degree relative diagnosed
before age 65) should begin talking with their doctor
at age 45 or earlier.
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• Primary cause is HPV infection
• When detected early, one of the easiest
cancers to treat successfully
• Death rates have declined steadily due to
screenings with Papanicolaou (Pap) Test
320
91
0
50
100
150
200
250
300
350
Diagnosed (new) Deaths
2015 Cervical Cancer in Virginia(Estimations)
Cervical Cancer
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Survival Rates
Stage at Diagnosis Stage
Distribution (%)
5-year Relative
Survival (%)
Localized 47 90.9
Regional 36 57.1
Distant 12 16.1
Unstaged 4 54.3
Stage Distribution and 5-year Relative Survival
by Stage at Diagnosis (2003-2009)
Source: Howlader N, Noone AM, Krapcho M, Garshell J, Neyman N, Altekruse SF, Kosary CL, Yu M, Ruhl J, Tatalovich Z,
Cho H, Mariotto A, Lewis DR, Chen HS, Feuer EJ, Cronin KA (eds). SEER Cancer Statistics Review, 1975-2010, National
Cancer Institute. Bethesda, MD, http://seer.cancer.gov/csr/1975_2010/, based on November 2012 SEER data submission,
posted to the SEER web site, 2013.
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Screening test:
• The Pap (test identifies abnormal changes in the cells of the cervix that may lead to cervical cancer
When to start?
• Age 21
Screening for Cervical Cancer
30% of cervical cancers and pre-cancers are not prevented by the HPV vaccine, regular Pap tests remain a vital part of women’s healthcare.
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Women in their 20’s
• All women should have first Pap test at age 21.
• Test should be done every 3 years.
SCREENING GUIDELINES
Women in their 30’s to mid - 60’s • Women 30-65 should have an HPV and Pap test every 5 years or
if only having the Pap test, screening should occur every 3 years.
• Women with certain risk factors may need more frequent testing.
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Women 65+
• Most women 65+ years of age who have had 3 or
more normal Pap tests or 2 or more normal HPV
and Pap test in a row within 10 years can choose
to stop having Pap tests.
• Women who have had a total hysterectomy may
also choose to stop having Pap tests.
SCREENING GUIDELINES (CONT.)
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HPV Vaccination – ACS Recommendations
There is no cure for HPV and the only sure way to prevent HPV is to abstain from
all sexual activity
To reduce your risk of acquiring a HPV infection:
Limit number of sexual partners
Practice safe sex
Condoms provide some, but not total, protection against HPV
Get the HPV vaccine before exposure
ACS recommends girls ages 11-12 receive the HPV vaccine at time of regular exam.
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Melanomas
• The most serious form of skin cancer is melanoma.
• Can occur anywhere on the body
• Almost always curable when detected early
• More likely to spread to other parts of body
• Lifetime risk of being diagnosed --
• Men: 1 in 35
• Women: 1 in 54
2015– U.S.
• 73, 870 expected diagnoses
• 9,940 deaths
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Survival Rates
Stage at Diagnosis Stage
Distribution (%)
5-year Relative Survival
(%)
Localized 84 98.3
Regional 9 62.4
Distant 4 16.0
Unstaged 4 76.5
Stage Distribution and 5-year Relative Survival
by Stage at Diagnosis (2003-2009)
Howlader N, Noone AM, Krapcho M, Garshell J, Neyman N, Altekruse SF, Kosary CL, Yu M, Ruhl J, Tatalovich Z, Cho H, Mariotto A,
Lewis DR, Chen HS, Feuer EJ, Cronin KA (eds). SEER Cancer Statistics Review, 1975-2010, National Cancer Institute. Bethesda, MD,
http://seer.cancer.gov/csr/1975_2010/, based on November 2012 SEER data submission, posted to the SEER web site, 2013.
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ABCD’s
•Asymmetry
•Borders (irregular)
•Color (variegated)
•Diameter (> 6 mm)
Itching, bleeding, scaling, changes or
new growths.
Melanoma warning signs
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Early Detection by a Physician Physical Exam (may include…)
• Noting the size, shape, color, and texture of the
area(s) in question,
• Checking for bleeding or scaling.
• Checking the rest of the body for spots and
moles that could be related to skin cancer.
• Feeling of the lymph nodes (small, bean shaped
collections of immune cells) under the skin in the
groin, underarm, or neck near the abnormal area.
Medical History (check…)
• When the mark on the skin first appeared,
• Changes in size or appearance,
• Any symptoms (pain, itching, bleeding, etc.).
• Exposures
Note: Many dermatologists use a technique called dermatoscopy to see spots on the skin more
clearly.
Skin Biopsies
• Shave
• Punch
• Incisional & Excisional
There are other types of biopsies for melanomas that have metastasized
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WOMEN Breast Yearly Mammogram starting age 40--earlier if
significant family history.
Clinical Breast Exam every 3 years for those 20-39; Yearly exams for age 40+.
Breast Self-Awareness – Be aware of how your breasts normally feel and report changes to your doctor
Colon Regular colon testing beginning at age 50. Earlier if
family history. Cervical Pap Test every 3 years starting at age 21-29. HPV & Pap every 5 years or every 3 years if Pap only
starting at age 30-65.
MEN
Colon
Regular colon testing beginning at age
50. Earlier if family history.
Prostate
Discuss with your doctor the benefits
and limitations of prostate cancer
testing starting at age 50, and high risk
individuals should start discussion at
age 45.
Summary of ACS Screening Guidelines
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At a periodic health examination, a cancer-related checkup should include:
• Health counseling, AND depending on a person’s age or gender,
• It should also include examinations for the following cancers:
• Thyroid
• Oral cavity
• Lymph nodes
• Testes
• Some non-malignant diseases
What about other cancers?
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Having Cancer is Hard. Finding help isn’t. Information on Cancer. Rides to Treatment. Financial Assistance. Wigs. Emotional Support.
All American Cancer Society services are free.
Call :1.800.ACS.2345 Visit: www.cancer.org
Call the American Cancer Society if you are affected by cancer
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How to get involved in the fight against cancer!
More than two million volunteers nationwide are currently making a difference in the fight against cancer.
We invite you to join them.
How? • Volunteer in local cancer centers
• Provide rides to cancer treatment • Join a community event such as Relay For Life
• Join ACS Cancer Action Network and contact legislators
on cancer issues Visit www.cancer.org to learn more!
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