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Update in cancer screening venezuela
 

Update in cancer screening venezuela

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  • Review some of the more familiar guidelines Review changes in the guidelines Review hot topics in cancer screening
  • Where does one find guidelines? Several sources, not all agree. Here are a few
  • Review criteria for what we should be screening for
  • Two types of screening tests for CRC Tests that detect precancerous lesions and cancers and tests that detect cancers These are tests that detect both precancerous and cancerous lesions. Note all require bowel prep. All have risks Note flex sig is still on the list
  • FOBT and immunochemical testing - note that the sensitivity is greatest with a yearly screening program - concept of program sensitivity
  • Hemoccult SENSA – more sensitive than other types of FOBT and the only one recommended Note on the testing after an examination – Don’t do it! Another point – repeated FOBT testing after a positive not recommended
  • DNA test relatively new Cost $300-400 Does not look for bleeding Multitarget – looks for many mutations, but this limits the sensitivity of test, since not all mutations are covered
  • One area worth reviewing is who is considered higher risk as opposed to average risk, since this will determine when to start screening as well as which test to recommend
  • Another frequently asked question is how often to perform colonoscopy, especially after a polyp is removed HNPCC = hereditary nonpolyposis colorectal cancer
  • Ovarian cancer is another area where we are often asked about screening Again, per the NCI, these are the recommendations using different modalities in average risk

Update in cancer screening venezuela Update in cancer screening venezuela Presentation Transcript

  • Update in Cancer Screening 2012 Yul D. Ejnes, MD, MACP Clinical Associate Professor of Medicine Warren Alpert Medical School of Brown University Immediate Past Chair, Board of Regents American College of Physicians
  • Update in Cancer Screening What’s old? What’s new (and sometimes controversial)? Cervical cancer screening Prostate cancer screening Lung cancer screening
  • Guideline Sources American Cancer Society www.cancer.org (search “screening guidelines”) US Preventive Services Task Force www.ahrq.gov/clinic/uspstfix.htm National Guideline Clearinghouse www.guideline.gov Specialty Societies pier.acponline.org PubMed www.pubmed.gov (use “Limits” to narrow search) National Cancer Institute www.cancer.gov/cancertopics/screening
  • Wilson and Jungner criteria forscreening (World Health Organization) Condition should be important Recognizable latent or early symptomatic stage Natural course of condition adequately understood Suitable test or examination Test acceptable to population Case finding should be continuous (not just a "once and for all" project) Accepted treatment for patients with recognized disease Facilities for diagnosis and treatment available Agreed policy concerning whom to treat as patients Costs of case finding (including diagnosis and treatment of patients diagnosed) economically balanced in relation to possible expenditures on medical care as whole JMG Wilson and G Jungner in Principles and Practice of Screening for Disease, WHO 1968
  • Breast Cancer Screening Breast self-examination – age 20+, optional, instruct if going to check Clinical breast examination – 20’s-30’s at least every 3 yrs @ periodic exam, ≥ 40 yearly @periodic exam Mammography – yearly ≥ 40 Inform on benefits and potential harms When to stop – individualized, stop when health poor and no longer candidate for treatment
  • Breast Cancer Screening 2009 – US Preventive Services Task Force (USPTF) issued guideline on breast cancer screening (Ann Intern Med. 2009;151:716-726,W-236) USPTF recommended screening for ages 40-49 based on informed decision making USPTF recommended biennial screening for ages 50-74 and concluded no evidence for or against ages ≥ 75 USPTF concluded no evidence for or against clinical breast exam in ages ≥ 40 Joint ACP/ACR ”talking points” at http://www.acpinternist.org/archives/2012/05/policy.htm
  • Breast Cancer Screening High risk women BRCA mutation carriers or likely carriers, other genetic syndromes, history of chest irradiation Annual screening mammography and MRI starting at age 30 for women known to have BRCA mutation, untested with 1st degree relatives with BRCA, or with lifetime risk of breast cancer of 20-25% Use of specialized breast cancer risk estimation models that incorporate family histories (not the “Gail model”)Saslow D, Boetes C, Burke W, et al. American Cancer Society guidelines for breastscreening with MRI as an adjunct to mammography. CA Cancer J Clin. 2007;57:75-89.
  • Gail Model (Breast Cancer Risk Assessment Tool)http://www.cancer.gov/bcrisktool/
  • Other Models for Calculating Breast Cancer RiskSaslow D, Boetes C, Burke W, et al. American Cancer Society guidelines for breastscreening with MRI as an adjunct to mammography. CA Cancer J Clin. 2007;57:75-89.
  • Colorectal Cancer ScreeningLevin B, et al, Screening and Surveillance for the Early Detection of Colorectal Cancer and Adenomatous Polyps,2008: A Joint Guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer,and the American College of Radiology CA Cancer J Clin 2008 58: 130-160
  • Colorectal Cancer ScreeningLevin B, et al, Screening and Surveillance for the Early Detection of Colorectal Cancer and Adenomatous Polyps,2008: A Joint Guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer,and the American College of Radiology CA Cancer J Clin 2008 58: 130-160
  • Fecal Occult Blood Testing (FOBT) A single-stool sample FOBT collected after digital rectal exam in the office is not an acceptable screening test, and it is not recommended. “Sensitive” gFOBT = Hemoccult SENSA, etc. – NOT Hemoccult II Positive test requires colonoscopy follow up!Levin B, et al, Screening and Surveillance for the Early Detection of Colorectal Cancer and Adenomatous Polyps,2008: A Joint Guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer,and the American College of Radiology CA Cancer J Clin 2008 58: 130-160
  • Fecal DNA Analysis Sensitivity: 52% - 91%; specificity: 93% - 97% Greater sensitivity than FOBT (data limited, used previous version of DNA analysis) Screening interval not known - ? 5 years Positive test requires colonoscopy Does not include markers for all adenomas and carcinomas ?significance of a “negative” colonoscopy
  • Who is at “higher risk” for CRC? History of adenomatous polyps History of curative-intent resection of CRC Family history of either CRC or colorectal adenomas diagnosed in a first-degree relative before age 60 years History of inflammatory bowel disease of significant duration Known or suspected presence of one of 2 hereditary syndromes, specifically hereditary nonpolyposis colon cancer or familial adenomatous polyposis.Smith, RA., Cokkinides, V, Brawley, OW, Cancer Screening in the United States, 2008: A Review of Current AmericanCancer Society Guidelines and Cancer Screening Issues, CA Cancer J Clin 2008 58: 161-179
  • Frequency of Colonoscopy Small rectal hyperplastic polyps = “normal:” 10 years 1 or 2 adenomas < 1 cm: 5 to 10 years, “depending” 3 to 10 adenomas, or > 1 cm, or villous features, or high-grade dysplasia: 3 years > 10 adenomas: < 3 years, consider familial syndrome Sessile adenomas removed piecemeal: 2 to 6 months, then less frequent HNPCC: more intensive follow upWinawer SJ, Zauber AG, Fletcher RH, et al. Guidelines for colonoscopy surveillance after polypectomy: aconsensus update by the US Multi-Society Task Force on Colorectal Cancer and the American Cancer Society.CA Cancer J Clin 2006;56:143–159.
  • Ovarian Cancer Screening CA 125 Levels, Transvaginal Ultrasound, and Pelvic Examinations Statement of benefit There is solid evidence to indicate that routine screening for ovarian cancer with the serum marker cancer antigen (CA )125 and transvaginal ultrasound (TVU) does not result in a decrease in mortality from ovarian cancer. Statement of harms Based on solid evidence, routine screening for ovarian cancer results in many diagnostic laparoscopies and laparotomies for each ovarian cancer found. http://www.cancer.gov/cancertopics/pdq/screening/ovarian/HealthProfessional/page1
  • Cervical Cancer Screening Updated 2012 – starting age 21,  frequency of testing American Cancer society and US Preventive Services Task Force issue updates simultaneously Co-testing – Papanicolau test + HPV testing Ages 21-29 – Papanicolau test q 3 years Ages 30-65 – Papanicolau test + HPV DNA q 5 years (or Papanicolau test along q 3 years)
  • Cervical Cancer Screening When to stop Age >65 Post hysterectomy/no cancer Exception: “high risk” (DES exposure, HIV, immunosuppression, history cervical cancer) – stop when health poor and no longer candidate for treatment
  • Prostate Cancer Screening ACS: in men > 10 yr life expectancy, shared decision making on digital rectal examination (DRE) and/or PSA Average risk – age 50 Higher risk – age 45 (African-Americans, family history < 65 y.o.) “Appreciably higher risk” (multiple family members) – age 40 Screening = PSA with/without DRE Frequency – q 2 yrs if <2.5 ng/ml, yearly if higher Referral for PSA > 4 ng/ml; individual risk assess for 2.5-4
  • Prostate Cancer ScreeningWolf AM, Wender RC, Etzioni RB, et al; American Cancer Society Prostate Cancer Advisory Committee. American CancerSociety guideline for the early detection of prostate cancer: update 2010. CA Cancer J Clin. 2010;60:70-98
  • Prostate Cancer Screening US Preventive Services Task Force draft (2011):The U.S. Preventive Services Task Force (USPSTF) recommends against prostate-specific antigen (PSA)-based screening for prostate cancer. This is a grade D recommendation Issues Accuracy of testing, effectiveness of early detection/treatment, harms of screening/treatment Net benefit – few deaths prevented/lives extended, harms of overdiagnosis/overtreatment “moderate to substantial” = no net benefit www.uspreventiveservicestaskforce.org/uspstf12/prostate/draftrecprostate.htm
  • Lung Cancer Screening Interim guidance in response to National Lung Screening Trial (NLST) study Adults meeting NLST criteria may consider screening Criteria Age 55-74, no signs/symptoms of lung cancer Active or former smoker with a 30 pack year history. Active smoker or former smoker, must have quit within 15 years Exclusions: Metallic implants/devices in the chest/back; home O2 need; history of lung cancer/other lung cancer symptoms
  • Lung Cancer Screening Shared decision making – pros and cons Should follow NLST protocol – annual screening Enrollment in screening program with expertise in low dose CT screening and evaluation/diagnosis/treatment of abnormalities Other groups not meeting criteria – ??? American Cancer Society. Interim Guidance on Lung Cancer Screening. Atlanta, GA: American Cancer Society; 2011. Available at: http://www.cancer.org/Healthy/FindCancerEarly/index. Accessed 2012