This document discusses cancer screening guidelines for women. It outlines the evidence and recommendations for screening of breast, cervical, colorectal, ovarian and lung cancers. Screening aims to detect cancers early through systematic testing of asymptomatic individuals. For breast cancer, annual mammograms are recommended starting at age 40. Cervical cancer screening involves Pap tests every 3 years from age 21. Colorectal cancer screening includes annual fecal occult blood tests and sigmoidoscopy every 5 years for those over age 50. While screening shows promise, limitations remain for ovarian and lung cancers. Guidelines aim to reduce cancer burdens through evidence-based screening strategies.

1. Cancer Screening In Women
Evidence Base Medicine
Khalid Sait (FRCSC)
Prof. - Consultant Obstetrics and Gynecological Oncology
KAUH, Jeddah, Saudi Arabia
khalidsait@yahoo.com
0505693160

2. Outline
Rational for screening
Evaluation of screening tests
Levels of evidence
Screening for selected cancers

3. Screening
a means of detecting disease early, in
a symptomatic individuals

4. Characteristics of Diseases Well-
suited for Screening
Important public health problem
Long, recognizable pre-symptomatic phase
Available treatment, which is favorably
affects its natural history
Treatment is more effective in the pre-
symptomatic phase
A suitable screening test exists

5. Why Screen for Cancer?
Outcome of cancer treatment is very
dependent on the stage of the disease when
diagnosis is made
Goal
Is to shift the extent of disease at diagnosis
from advanced to early through the
systematic examination of a symptomatic
and symptomatic women

6. Scientific Basis
Requirements that must be met for
screening to be useful:
 There must be a test or procedure that will
detect cancers earlier
 There must be evidence that treatment at an
earlier stage of disease will result in an
improved outcome
Proof of benefit
 Demonstration of a decrease in cause-specific
mortality

7. Screening Tests
Examinations, tests, or procedures are not
diagnostic of cancer
They indicate that a cancer may be present
The diagnosis is then made following
further tests that may include a biopsy and
pathologic confirmation

8. Characteristics of a Good
Screening Test
Acceptable
Inexpensive
Widely available
Safe
Accurate

9. Accuracy of the Test?
Reliability: Do you get the same results
each time?
Validity: Does the test measure what it says
it's measuring?
Sensitivity: If the disease is present, how
often does the test detect it?
Specificity: If the disease is absent, how
often does the test give negative results?

10. Sensitivity
Proportion of people with the disease who
test positive in the screen
 i.e., The ability of the test to detect disease
when it is present
Relatively independent of prevalence

11. Specificity
Proportion of people who do not have the
disease and test negative in the screen
 (i.e., The ability of a test to tell that The
disease is not present)
Relatively independent of prevalence

12. Predictive Values
Positive predictive value
 Proportion of persons who test positive and
have the disease
Negative predictive value
 Proportion of persons who test negative and do
not have the disease
Depends on prevalence of disease (Pretest
probability)

13. Assessment of Screening Tests
Best evidence to support the usefulness of screening:
Randomized, controlled screening trial with cause-specific
morality as the end-point
- The group receiving the screening test has a better cause-
specific morality rate than the control group
Case control and cohort studies (Weaker Evidence)
Reduction in the incidence of advanced-stage disease
Improved survival
Stage shift (to earlier stage)

14. Levels of Evidence
Level 1: evidence obtained from at least one randomized
controlled trial
Level 2: evidence obtained from controlled trials without
randomization
Level 3: evidence obtained from cohort or case-control
analytic studies, preferably from more than one center or
research group
Level 4: evidence obtained from multiple-time series with
or without intervention
Level 5: opinions of respected authorities based on clinical
experience, descriptive studies, or reports of expert
committees

15. Breast Cancer
Leading cause of cancer death in women
Leading cause of death in women aged 40
to 45
Goal of screening is detection of early stage
and in-situ disease that has better prognosis

16. Tools of Breast Cancer Screening
1. Mammogram
2. Breast self-examination
3. Clinical examination

17. Tools of Breast Cancer Screening
1. Mammogram
Mammogram: major screening tool
Mammogram is less sensitive in younger women
It has lower positive predictive value in younger
women
Best supporting evidence

18. Tools of Breast Cancer Screening
2. Clinical examination
Optimal technique?
Sensitivity 55 to 60%
Specificity 95%
Abnormal exam. and a normal mammogram
was associated with a cancer detection rate
of 7.4 per 1000 records (555983 records)
Supplement mammogram

19. Tools of Breast Cancer Screening
3. Breast self-examination
No controlled data available
Safe and free!

20. Recommendations of ACS(2004)
1. Monthly breast self-examination:
 No longer recommended beginning at age of 20 years
 Recommends that women should be informed about the
potential benefits and limitations associated with BSE and that
women may choose to do BSE regularly, occasionally , or not at
all.
 Education of symptoms
2. Clinical breast examination:
 20 –39 years: every 3 years
 40+ years: annual
3. Mammogram:
 40+ years: annual

21. Recommendations of ACS(2004)
High risk patients
When to stop screening?

22. Cervical Cancer
Squamous cell carcinoma of cervix strongly
associated with persistent infection with certain
subtypes of human papilloma virus (HPV)
Development of invasive cancer is preceded by
well-defined precancerous lesions
Pap smear very effective in detecting precancerous
lesions
Pap smear relatively inexpensive and accepted by
medical profession and (?) the public

23. Evidence of Benefit
There has been a fall in the incidence and
mortality from cervical cancer that followed the
introduction of screening program
Iceland: 80% reduction in mortality over 20 years
Finland: 50% reduction
Sweden: 34% reduction
level of evidence 3, 4, 5

24. HPV DNA Testing with Cytology for the Screening
of cervical Cancer and its precursor Lesions
Not yet approved by FDA for screening
Based on the available data, both published and
unpublished , the ACS guideline review panel
found this technology to be promising
Should the FDA approve HPV DNA testing for
this purpose , it would be reasonable to consider
that for women aged 30 and over , as alternative to
cervical cytology testing alone .

25. Recommendations of ACS(2004)
Start three years after onset of vaginal intercourse,
no later than age 21 years old then do it annually
for convention pap and every two year for thin
prep.
after age of 30 pap can be done every three years
in no risk women
HIV patient: Twice a year after initial diagnosis
then yearly if negative
Once patient reach 70 years old and had no
abnormal pap in previous 10 years pap test
become unnecessary
Not indicated for women who had total
hysterectomy for benign disease

26. Colorectal Cancer
2nd leading cause of cancer death in US
Most cases diagnosed after age 50
Goal of screening:
 Detection and removal of polyps to prevent
development of cancer
 Detection of early stage disease

27. Tools of Colorectal Screening
1. Fecal occult blood detection
2. Endoscopy
 Flexible sigmoidoscopy
 Colonoscopy
3. Radiographic studies
 Single contrast barium enema
 Double contrast barium enema

28. Fecal Occult Blood (FOB)
Usual source of blood
 Cancer
 Large polyp (> 2 cm)
 Decreased the 13 years cumulative mortality by 33 %
 Sensitivity 26 %
 Specificity 95%
Cost effective as the only test
Level of evidence 1

29. Fecal Occult Blood (FOB)
Recommendations for proper testing:
Preparatory diet
3 serial specimens
Avoidance of NSAID (except for low dose
ASA for vascular disease)
Single test during rectal exam not
recommended

30. Flexible Sigmoidoscopy
Less than half of colon examined
Poorer performance than FOB or colonoscopy
over 10 years
Case control studies 60-80 % reduction in
mortality with high sensitivity and specificity
Yearly FOB and sigmoidoscopy every 5 years
equivalent to colonoscopy every 10 years
Level of evidence 3, 4, 5

31. Recommendation of ACS(2004)
Age 50+
1. Fecal occult blood every year
OR 2. Flexible sigmoidoscopy every 5 years
OR 3. Fecal occult blood every year and flexible
sigmoidoscopy every 5 years
OR 4. Double contrast barium enema every 5 years
OR 5. Colonoscopy every 10 years starting at
age 50

32. Recommendation of ACS(2004)
Intensive surveillance for:
1- Person at increase risk due to history of
adenomatous polyps
2- History of curative intent resection of colorectal
cancer
3- History of colorectal cancer or adenoma
diagnosed in first degree relative before age 60
years
4- History of long duration IBD
5- Patient at risk of hereditary syndrome

33. Epithelial Ovarian Cancer
26,000 new cases diagnosed each year, 14,000 die
Incidence: 1.4:100000(age <40)
45:100000(age >60)
Life time risk is 1:70
5 % are familial
One 1st degree relative – 3 to 4%
Two first degree relatives > 15%

34. Epithelial Ovarian Cancer
No pre-malignant lesion and symptoms
cannot be relied on to identify women with
early disease but pt. With early stage are
ass. With good prognosis)
Little is know about natural history and rate
of progression

35. Screening methods
USS or CA 125 alone has too low PPV
CA125 and USS regimens being studied
Doppler Imaging

36. CA 125
Correlates with stage of disease
Increase 90 % - Stage II,III,IV
Increase 50 % - Stage I

37. CA 125 and Ovarian cancer
Pre menopausal Post
menopausal Sensitivity
84 % 50 %
Specificity 69% 92 %

38. Color Doppler and Ovarian Cancer
The new vasculature that arise in malignant
contains less smooth muscle than its offer less
resistant to blood flow (>0.4) this can measure as
pulstil index of the vessels
Vascular pattern
Scoring system
Sensitivity of 96 % and specifity of 98 %

39. Screening for ovarian cancer
No adequate test
Screening Not yet cost effective
Difficult to no how often to screen
Trials are under taken for general
population as well as high risk group
Data too limited to recommend, However
BME and education of women should be
done about symptom and signs

40. Endometrial Cancer
36,000 new cases diagnosed in USA each
year , 6500 dies
It is primarily a disease of the
postmenopausal female( 25 % occurring in
patients younger than 40 years of age )

41. Recommendation of ACS(2004)
Women with average or mod. risk should be inform about
risks and symptoms of endometrial cancer at the onset of
menopause and strongly encourage to report any
unexpected bleeding or spotting to physicians
Very high risk patients:
Annual screening begin at age 35
recommendation base on expert opinion in the
absent of defentive scientific evidence , should
also be informed about the benefit and risk and
limitation of testing in endometrial cancer
screening

42. Lung Cancer
Leading cause of cancer death in women in US
High case fatality
Early randomized studies using chest X-ray, and
sputum cytology in smokers were negative
Recent data using low dose CT suggests a benefit.
Data too limited to recommend

43. Other ACS Recommendations
Cancer related check-up for 20+
 20-39 every 3 years
 40+ annually
Examination of thyroid, lymph nodes, oral cavity
and skin
Health counseling about tobacco, sun exposure,
diet, nutrition, risk factors, sexual practices and
environmental and occupational exposures

44. Conclusions
Guideline for cancer screening
represent evidence – based
strategies for reducing the
morbidity and mortality rate
associated with late – stage
diagnosis of specific cancer.

45. Conclusions
Three sectors in the society:
1- Health care system , which make cancer
screening available to eligible populations
2- Health care providers, who should counsel
patients about recommended cancer screening
and assure that screening is performed in a
timely manner
3- Individual, who should heed the
recommendations made by public health agencies
and their physician on screening and obtain
recommended screening test and pursue follow up
tests

46. Cancer Screening In Women
Evidence Base Medicine
Dr Khalid Sait (FRCSC)
Ass. Prof. - Consultant Obstetrics and Gynecological oncology
KAUH, Jeddah, Saudi Arabia
khalidsait@yahoo.com
0505693160
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