This document discusses cancer screening for seniors and whether it makes sense. It notes that reasons not to screen everyone include costs, potential harms from false positives or procedures, and factors related to life expectancy and health status. It provides examples of famous people who died of pancreatic cancer and notes that screening for pancreatic cancer is not recommended. It asks questions about the most common cancers, typical cancer ages, beneficial screening tests, and best screening advice. It discusses stopping screening at age 75 but continuing for those expected to live 10 more years. It provides resources on cancer screening guidelines.

1. Cancer Screening for
Seniors
Does it make sense?
ASPEC December 2020
Robert Miller MD
www.aboutcancer.com
tinyurl.com/robertmillermd

2. Should you be continuing to get tests to look
for cancer?

3. Reasons not to screen everyone
1. Expensive
2. Harm (false positives and risk of procedure)
3. Too old?
1. Life expectancy so short they won’t likely develop a new cancer
2. Health status is so poor they may be too sick to be treated even if cancer is
found
3. Patient may decline or refuse to be treated
4. Won’t help
1. Cancer so indolent it will never hurt them (? Prostate cancer)
2. Cancer too advanced there is no effective therapy (?pancreas cancer)

4. Famous People Who Died from Pancreas Cancer
Alex Trebek Steve Jobs
Ruth Bader Ginsburg
Do you worry about pancreas cancer?

6. uspreventiveservicestaskforce.org/
Clinical Summary - Pancreatic Cancer: Screening --Asymptomatic Adults
Recommendation
Do not screen.
Grade: D
The USPSTF does not recommend screening for pancreatic cancer in the general population using any method.
Imaging-based methods, such as the computed tomography scan, magnetic resonance imaging, and
endoscopic ultrasonography, have been studied as screening tests in trials of screening persons at high risk of
pancreatic cancer due to inherited genetic syndromes or familial pancreatic cancer.
There are currently no accurate, validated biomarkers for early detection of pancreatic cancer.

7. 1.What are the most common cancers?
2.What age do people typically get
cancer?
3.What screening tests have been shown to be
beneficial?
4.Where do you find the best advice on
screening?
5.At my age is it still worth screening?

8. Most Common Cancers in the US in 2020

9. Most Lethal Cancers in the US in 2020

10. In 2020 in the US there would be over 1.8 million new
cancer cases and over 600,000 deaths from cancer.
The probability of getting cancer during your lifetime
based on data from 2014 to 2016 is 40.1% for men and
38.7% for women (not counting skin cancers).

12. Scientifically what is known about the effectiveness of cancer
screening? Where is there proven value?
Answer: cervix, colorectal, breast, lung, (? prostate)
Which or whose guidelines should I follow?
American Cancer Society : NO
National Cancer Institute: NO
NCCN: No
USPSTF: Yes (what??)

13. What age to stop screening?
US Preventive Service Task Force says 75 (Pap smears at 65y)
How many patients over 75 are still getting screening?
Mammograms: 62%
Pap Smears: 53%
Colonoscopy: 57%
PSA: 57%
Archives Internal Medicine Dec 26, 2011

14. NCCN.Org

15. Cancer in Older Adults
• Cancer is the leading cause of death in men and women aged 60-79
• More than 50% of all cancers and 70% of all cancer deaths occur in people 65 or older
• By 2030 approximately 70% of all cancers will be diagnosed in people 65y or older

16. Probability (%) of Developing Invasive Cancer Within Selected
Age Intervals by Sex, United States, 2014 to 2016
Age: 0-49 50-59 60-69 70+ Total
All sites
Male 3.5% 6.2% 13.3% 32.7% 40.1%
Female 5.8% 6.4% 10.2% 26.7% 38.7%
men 32.7/40.1 (82%) women 26.7/38.7 (69%) occur in people 70 or older

17. Probability (%) of Developing ColoRectal Cancer Within Selected
Age Intervals by Sex, United States, 2014 to 2016
Age: 0-49 50-59 60-69 70+ Total
Colon or Rectal
Male 0.4% 0.7% 1.1% 3.3% 4.4%
Female 0.4% 0.5% 0.8% 3.0% 4.1%
Men: 3.3/4.4 (75%) and women 3.0/4.1 (73%) occur after 70

18. Probability (%) of Developing Breast or Prostate Cancer Within
Selected Age Intervals by Sex, United States, 2014 to 2016
Age: 0-49 50-59 60-69 70+ Total
Prostate or Breast
Male 0.2% 1.8% 4.7% 8.2% 11.6%
Female 2.0% 2.4% 3.5% 7.0% 12.8%
Men: 8.2/11.6 (71%) and women 7.0/12.8 (55%)

19. Probability of Developing Cancer

20. Stop screening at age 75 y but can continue if heathy and expected to live
another 10 years

21. Stop screening at age 75 y but can continue if heathy and expected to live
another 10 years

22. Key Web Sites for Cancer Prevention and Screening
www.aboutcancer.com Dr. Miller Site
cancer.gov/about-cancer/causes-prevention NCI prevention Site
www.cancer.gov/types NCI specific cancers
seer.cancer.gov/ Cancer Statistics
epss.ahrq.gov/PDA/index.jsp Screening Guidelines
www.nccn.org National Comprehensive
Cancer Network (NCCN)
Uptodate.com Current review article about all
medicine
gis.cdc.gov/Cancer/USCS/DataViz.html CDC Cancer Risk Graphs
https://health.gov/dietaryguidelines/2015 Diet Guidelines

24. http://epss.ahrq.gov/PDA/index.jsp
Search epss
in your app
store

26. https://www.uspreventiveservicestaskforce.org/webview

28. What tests should a 70y old woman be having done?

31. DO NOT RECOMMEND

32. DO NOT RECOMMEND

33. Change the age of the woman to 80, there are no A or B cancer screening
recommendations just a C for colorectal
•The decision to screen for colorectal cancer in adults aged 76 to 85 years should be an individual one, taking into
account the patient’s overall health and prior screening history.
•Adults in this age group who have never been screened for colorectal cancer are more likely to benefit.
•Screening would be most appropriate among adults who 1) are healthy enough to undergo treatment if colorectal
cancer is detected and 2) do not have comorbid conditions that would significantly limit their life expectancy

35. Stool guaiac chemical test for blood (heme, human and animal) / FIT is immunologic test for human globin within
hemoglobin / Stool DNA looks for cancer DNA (Cologuard)
SEPT9 DNA blood test (serum) may be a future option

37. Patient Compliance
How often the patient agrees to get screened based
on what options the doctor gives them:
Stool Test 67%
Stool Sample Test or Colonoscopy 69%
Colonoscopy 38%
Study in Australia showed that as long as they had one of these done, the risk of colon cancer was reduced by 44%

43. It’s Complicated Who Needs to be Screened for Lung Cancer

44. It all Depends on How Big the Spot Is

45. Stereotactic body radiation therapy (SBRT) is a technique that utilizes precisely
targeted radiation to a tumor while minimizing radiation to adjacent normal tissue. This
targeting allows treatment of small- or moderate-sized tumors in either a single or
limited number of dose fractions.
SBRT has been defined by the American College of Radiology (ACR) and American
Society for Radiation Oncology (ASTRO) as the use of very large doses per fraction
SBRT

46. PET before SBRT Target PET 2 months Later
80 yo man with adenocarcinoma LUL / Tomo 10Gy X 5

47. Jeppesen. IJROBP 2014;90:S642
SBRT No Rx
Survival 40 months 9.9 months
Survival/5y 37% 6%
Lung Cancer
cause of death
39% 77%
Trying Radiosurgery (SBRT) is Better than Doing Nothing

50. Data to Justify or Explain Their Recommendation

52. Advice from the American Cancer Society

66. There are at least 6 Prognostic Groups of Prostate Cancer

67. In VERY LOW RISK
Based on life
expectancy ( of at
least 10 years or 20
or more ) there are
3 possible options
to consider

68. In LOW RISK
Based on life
expectancy ( of at
least 10 years) the
options would be 1.
to watch closely or
2. go ahead and
treat (with radiation
but not surgery) or
3. casual
observation

69. In HIGH RISK
Based on life
expectancy ( of at
least 5 years) there
are 6 options to
consider

70. https://www.cancer.gov/types

72. Endometrial Cancer Prevention
KEY POINTS
Avoiding risk factors and increasing protective factors may help prevent cancer.
The following risk factors increase the risk of endometrial cancer:
Endometrial hyperplasia
Estrogen
Tamoxifen
Obesity, weight gain, metabolic syndrome, and diabetes
Genetic factors
The following protective factors decrease the risk of endometrial cancer:
Pregnancy and breast-feeding
Combination oral contraceptives
Physical activity
Cigarette smoking
It is not known if the following factors affect the risk of endometrial cancer:
Weight loss
Fruits, vegetables, and vitamins
Cancer prevention clinical trials are used to study ways to prevent cancer.
New ways to prevent endometrial cancer are being studied in clinical trials.

73. Endometrial Cancer Screening
KEY POINTS
Tests are used to screen for different types of cancer when a
person does not have symptoms.
Endometrial cancer is usually found early.
There is no standard or routine screening test for endometrial
cancer.
Tests that may detect (find) endometrial cancer are being
studied:
Pap test
Transvaginal ultrasound
Endometrial sampling
Screening tests for endometrial cancer are being studied in
clinical trials.

74. Amid Pandemic, Scientists Reassess Routine Medical
CareAll this year, patients stayed away from doctors’ offices in droves, postponing tests
and treatments. Maybe there’s a silver lining.
The number of mammograms plunged by 87 percent, colonoscopies
by 90 percent and Pap smears by 87 percent.
PSA tests for prostate cancer declined by 60 percent.
But was it all bad? Or were there benefits?
https://www.nytimes.com/2020/12/12/health/pandemic-routine-medical-care.html

76. https://www.nytimes.com/interactive/2020/12/13/us/deaths-
covid-other-causes.html?smid=em-share
Not from Cancer (so far)

77. What’s New?

78. Only 25% of cancers are detected by
screening (early cancers) but 75% not until
there are symptoms (more advanced)

79. Conventional Screening Tests are only Available for about
30% of Cancers Diagnosed Every Year

80. Using Liquid Biopsy to Screen for Cancer

81. Johns Hopkins University set out to develop a blood test that could detect several types of cancer and pinpoint
their source. They focused on eight cancer types: breast, colorectal, esophagus, liver, lung, ovary, pancreas,
and stomach.
Results appeared online on January 18, 2018, in Science. most effective combination of known mutations to
identify cancers using circulating tumor DNA (ctDNA)—pieces of DNA in the bloodstream that have been
released from cancer cells.
Overall, CancerSEEK detected 70% of the cancers. Sensitivity ranged from 98% for ovarian cancers to
33% for breast cancers.
Sensitivity varied by cancer stage: 78% for Stage III cancers; 73% for Stage II cancers; and 43% for Stage I
cancers.
Only 7 of the 812 people without known cancers scored positive (>99% specificity).
The scientists estimate that the test will cost less than $500. The eight cancer types studied account for
more than half of cancer deaths nationwide, and current screening tests with proven benefit are limited to
only a few types of cancer.

82. thrivedetect.com/cancerseek/

83. An early version of CancerSEEK developed in 2016 was
evaluated in DETECT-A, a study of 10,006 women between the
ages of 65 to 75 without a prior cancer history.
The results, published in Science in April 2020, demonstrated that
our blood test more than doubled the number of cancers that were
first detected through screening, identified 65% of cancers at earlier
stages, and identified cancers across 10 organs, seven of which
have no recommended standard-of-care tests.