3. Palabras
La Real Academia Española define tamizar como depurar,
elegir con cuidado y minuciosidad.
En Inglés existe la palabra screening que significa la
evaluación o examen sistemático para la detectar una
sustancia o atributo indeseado.
Cribar es definido como realizar un examen médico a un
conjunto de personas para detectar una determinada
enfermedad y descartar otras.
Ni tamizaje, ni screening son castizas, pero se usan con
mayor frecuencia que cribado, que sería la más apropiada en
el castellano.
En este documento se utilizarán las tres palabras en forma
indistinta.
4. Tamizaje
El tamizaje consiste en la realización de
exámenes a personas asintomáticas con el fin
de detectar anormalidades intervenibles y
evitar desenlaces desfavorables.
En el tamizaje del cáncer se busca la detección
de lesiones premalignas, en fases preinvasivas
o en estadíos tempranos siempre y cuando las
intervencines terapéuticas en estas fases de la
enfermedad se traduzcan en una mejor
supervivencia en la población tamizada.
6. Screening for a disease
Going out and trying to find a disease early,
before it has caused symptoms.
The logic is that if we find a disease early, we can
cure it.
We hope people will live longer than if we waited
until the disease became symptomatic
Prasad V, Ending Medical Reversal, 2016
7. Effective cancer screening should accomplish
IT SHOULD FIND CANCERS EARLY IT SHOULD LOWER THE RATE OF
DYING FROM THE CANCER IT IS
MEANT TO FIND
IT SHOULD IMPROVE OVERALL
SURIVIVAL
Prasad V, Ending Medical Reversal, 2016
9. Overdiagnosis bias
1000 patients with
progressive cancer 600 dead
5-years
5-year survival: 80%
2000 patients with non-
progressive cancer 2400 alive
400 alive
1000 patients with
progressive cancer 600 dead
5-years
5-year survival: 40%
10. Dead at age 70
Cancer diagnosis because of
symptoms at age 67
Lead-time bias
No screening mammography
5-year survival: 0%
11. Dead at age 70
Cancer diagnosis because of
screening at age 60
Lead-time bias
Screening mammography
5-year survival: 100%
12. Dead at age 70
Cancer diagnosis because of
symptoms at age 67
Dead at age 70
Cancer diagnosis because of
screening at age 60
Lead-time bias
No screening mammography
Screening mammography
5-year survival: 0%
5-year survival: 100%
16. Cancer-screening tests
Mammography
Breast cancer
• Early detection
PSA
Prostate cancer
• Early detection
Colonoscopy
Colorectal cancer
• Detection or precancerous lesions
Chest CT scan
Lung cancer
• Early detection
Pap-smear
Cervical cancer
• Detection of precancerous lesions
17. Do cancer-screening tests fulfill their goals?
Screening-test Early detection /
prevention
Decrease cancer-related
mortality
Improve overall
survival
Mammography Yes Yes; ages 50 and older No
PSA Yes Some trials, minor impact No
Sigmoidoscopy and FOBT Yes Yes No
Chest-CT Yes Yes Yes
Pap-smear Yes Yes, indirect evidence Not proven
FOBT: Fecal occult blood test Prasad V, Ending Medical Reversal, 2016
18. Colon cancer screening: 30 years of follow-up?
Prasad V, Ending Medical Reversal, 2016
N Screened Not screened
Deaths due to
colon cancer
All deaths Deaths due to
colon cancer
All deaths
For every
10.000
persons
128 7,111 192 7,109
20. Inspired by: Prasad V, Ending Medical Reversal, 2016
Measuredincidence
Time
How a screening test should work
Incidence of
early cancers
Incidence of
Advanced cancers
21. Inspired by: Prasad V, Ending Medical Reversal, 2016
Measuredincidence
Time
Incidence of
early cancers
Incidence of
Advanced cancers
What actually happened with breast and prostate cancer
screening
Actual Incidence of
early cancers
Actual Incidence of
Advanced cancers
23. Overdiagnosis
in screen-
detected
cancer
• We end up treating around 40 prostate cancers
for every cancer that will kill.
• For each cancer detected by mammogram and
treated there is a 13 percent chance that
mammogram saved a life.
Prasad V, Ending Medical Reversal, 2016
24. Breast cancer screening: 30 years of follow-up?
Prasad V, Ending Medical Reversal, 2016
N Before mammography After 30 yr of screening
mammography
Early cancers Advanced Early cancers All deaths
For every
100.000
women
112/yr 102/yr 234/yr 94/yr
25. Effect of Three
Decades of Screening
Mammography on
Breast-Cancer
Incidence
https://www.nejm.org/doi/full/10.1056/NEJMoa1206809
Bleyer A, Welch HG. NEJM, 2012.
26. Autoridades que recomiendan tamizaje
Ministerio de Salud de
Colombia
American Cancer Society
(ACS) de Estados Unidos
USPSTF de Estados
Unidos
NCCN…
28. The breasts
can be
evaluated by
non-invasive
means
Self-exam
Clinical breast examination
Ultrasound
Mammography
MRI
29. The breasts
can be
evaluated by
non-invasive
means
• Proven NOT to be an effective screening strategy
Self-exam
• Proven NOT to be an effective screening strategy
Clinical breast examination
• Not an effective screening strategy
Ultrasound
• The only test that has DEMONSTRATED some BC-related
survival benefit
Mammography
• Reserved for high-risk patients (ie, BRCA1/2 carriers, prior
chest irradiation), based on INTUITION
MRI
31. Mamografía
Iniciar a los
40-45 años
Mamografía cada
1-2 años,
especialmente
entre los 45 y 55.
Continuar hasta
al menos los 70
años de edad.
32. Bi-Rads
Bi-rads Comments Recommendation
0 Unable to provide BC risk information Complement with other imaging
modalities
I Normal Continue with regular screening interval
II Abnormal, but not likely to be cancer Continue with regular screening interval
III Abnormal, with low risk of cancer (≤3%) Consider repeating imaging modality in
3 to 6 months; or complement with
other imaging modalities; or biopsy
IV Abnormal, with high risk of cancer (>3%).
Further classified as IVa: BC risk >3-10%; IVb:
BC risk 10-50%, IVc: BC risk 10-95%
Biopsy
V Risk of BC ≥ 95% Biopsy
36. 48 years-old, no prior history of BC, DCIS, breast
biopsy, thoracic radiation, BRCA1/2. No family
history of BC/Ovarian
http://www.breastscreeningdecisions.com/
37. Is screening
effective in
reducing
mortality?
• Screening reduces breast cancer mortality
15%-20%
• Women 40-59 y: reduction in breast
cancer mortality smaller magnitude and
less statistically significant
• Women 60-69 y, reduction highly
significant
• Women 70-74 y, reduction has not been
shown to be significant
• Screening has not been shown to reduce
all-cause mortality
38. What is the
current
evidence for
screening
women in
their 40s?
• USPSTF: 8% reduced risk breast cancer
mortality
• ACS: 15% reduced risk breast cancer
mortality
• Initiating screening at age 40 averts about 1
breast cancer death per 1000 women
screened
• Most averted deaths among women
aged 45–49
• Harms include false-positive results and
overdiagnosis
40. What are the
harms?
• False positive results
• Unnecessary follow-up tests and biopsies
• Anxiety and psychological distress
• Overdiagnosis
• Cancer that would never have progressed to
clinical importance in absence of screening
• Harms of treatment without any benefit
• Once a cancer is diagnosed, no way to
determine whether it is a case of
overdiagnosis
• Radiation exposure (may be a small risk)
41. When should
average-risk
patients stop
screening?
• Breast cancer incidence increases with age
• 26% breast cancer deaths attributed to
diagnosis at >74y
• Continue biennial screening until the
remaining life expectancy is about 10 years
• Biennial screening estimated to reduce
breast cancer deaths and harms for
women in their 70s
• Benefit of screening is low among women
≥80
43. No universal consensus exists
about the ultimate benefit of
screening mammography for
average-risk individuals
44. Two sides on early
detection (ED) with
screening mammography
• ED leads to a decrease in BC
mortality
• At least in 50-69 years-old
• If no adjuvant chemotherapy
is to be delivered once
cancer is found (ie,
Scandinavia)
• ED does NOT lead to a decrease in
BC mortality
• In countries in which
adjuvant chemotherapy is
available to early-breast
cancer
• ED does NOT decrease ALL cause
mortality
• ED greatly increases overdiagosis,
leading to overtreatment, among
other ills
45. Explain to your patient the
potential risks and benefits
of early-detection strategies
BEFORE initiating them
46.
47. Cribado:
Cáncer de
mama
Smith, R. A., Andrews, K., Brooks, D., DeSantis, C. E., Fedewa, S. A., Lortet-Tieulent, J., … Wender, R. C. (2016). Cancer screening in the
United States, 2016: A review of current American Cancer Society guidelines and current issues in cancer screening. CA: A Cancer Journal
for Clinicians, 66(2), 95–114. https://doi.org/10.3322/caac.21336
www.minsalud.gov.co
Colombia: “se recomienda la enseñanza del autoexamen como estrategia
de concientización y autoconocimiento.”
TEST CATEGORÍA ACS COLOMBIA
Mamografía Recomendación Anual, entre 45-54 años. A
partir de 55, se puede optar
por mamografía cada 2 años
Cada 2 años,
entre los 50-69
años
Opción Mamografía entre 40 y 44
años
Examen
clínico
Recomendación No se recomienda Cada año, a partir
de los 40
Autoexamen No se recomienda No se recomienda
48. Cribado: Cáncer de mama
Ministerio de Salud de Colombia
La decisión de iniciar tamización regular con mamografía cada
dos años antes de los 50 años debe ser individual y debe tener en
cuenta el contexto del paciente incluyendo sus valores en relación
con beneficios y daños.
Se recomienda la enseñanza del autoexamen como estrategia de
concientización y autoconocimiento.
49. Cribado: Cáncer de mama
Ministerio de Salud de Colombia
Recomienda realizar tamización de base poblacional organizada
mediante mamografía cada dos años en mujeres de 50 a 69 años
de edad*.
No recomiendan realizar tamización de rutina con mamografía en
mujeres de 40-49 años de edad.
*USPSTF recomienda hasta los 74 años
50. Screening for Prostate Cancer
US Preventive Services Task Force
Recommendation Statement
JAMA. 2018;319(18):1901-1913.
doi:10.1001/jama.2018.3710
52. The evidence
• PSA-based screening for prostate cancer has been studied
in 3 very large RCTs, each with at least a decade of median
follow-up:
• US-based Prostate, Lung, Colorectal, and Ovarian
(PLCO) Cancer Screening Trial
• European Randomized Study of Screening for Prostate
Cancer (ERSPC)a
• Cluster Randomized Trial of PSA Testing for Prostate
Cancer (CAP).
• These trials used varying screening intervals (from 1-time
screening to every 1 to 4 years) and PSA thresholds (2.5 to
10.0 ng/mL) for diagnostic biopsy.
53. PLCO
The PLCO trial may be viewed as a trial of organized vs opportunistic screening for prostate
cancer because of the substantial screening rate in the control group and the high screening
rate among men in both the control and intervention groups prior to study enrollment.
Men in the intervention group were screened more often than men in the control group, and
more men in the intervention group were diagnosed with prostate cancer than in the control
group.
The trial found no difference between groups in death from prostate cancer after almost 15
years of follow-up (absolute risk, 4.8 per 1000 person-years in the intervention group vs 4.6
per 1000 person-years in the control group; relative risk [RR], 1.04 [95% CI, 0.87-1.24]).
54. ERSPC
In the ERSPC trial, the results suggest that, overall, the number needed to screen is 781 men aged 55 to 69 years at
enrollment (95% CI, 490-1929) to prevent 1 man from dying of prostate cancer after 13 years.
The results varied across the individual ERSPC sites, and prostate cancer mortality was significantly reduced only at the
sites in the Netherlands and Sweden.
However, point estimates were in favor of screening at all sites except Switzerland.
At the largest site (Finland), there was no significant benefit observed for prostate cancer mortality (rate ratio, 0.91
[95% CI, 0.75-1.10]), and in Sweden there was an absolute risk reduction of 0.72% (95% CI, 0.50%-0.94%), a 42%
relative reduction.
55. ERSPC
Four ERSPC trial sites reported data on the effect of PSA-based screening
for prostate cancer on the development of metastatic cancer after 12 years
of follow-up.
The risk of developing metastatic prostate cancer was 30% lower among
men randomized to screening than among men in the control group
(absolute risk, 7.05 per 1000 men in the screening group vs 10.14 per
1000 men in the control group [calculated from numbers in the study]).
This translates to an absolute reduction in the long-term risk of
metastatic prostate cancer of 3.1 cases per 1000 men screened.
56. CAP
The CAP trial was a
cluster-randomized trial of
a single invitation to PSA-
based screening in the
United Kingdom among
415 357 men.
Overall, 34% of invited
men received a valid PSA
screening test.
After a median follow-up
of 10 years, there was no
significant difference in
prostate cancer mortality
between the invited group
and the control group
(absolute risk, 0.30 per
1000 person-years vs 0.31
per 1000 person-years,
respectively).
57. Screening for prostate cancer
– USPSTF
• Adequate evidence from randomized clinical trials shows
that PSA-based screening programs in men aged 55 to 69
years may prevent approximately 1.3 deaths from prostate
cancer over approximately 13 years per 1000 men
screened.
• Screening programs may also prevent approximately 3
cases of metastatic prostate cancer per 1000 men
screened.
JAMA. 2018;319(18):1901-1913.
doi:10.1001/jama.2018.3710
58. Screening for prostate cancer
– USPSTF
• Potential harms of screening include frequent
false-positive results and psychological harms.
• Harms of prostate cancer treatment include
erectile dysfunction, urinary incontinence, and
bowel symptoms.
• About 1 in 5 men who undergo radical
prostatectomy develop long-term urinary
incontinence, and 2 in 3 men will experience
long-term erectile dysfunction.
JAMA. 2018;319(18):1901-1913.
doi:10.1001/jama.2018.3710
59. Screening for prostate cancer
– USPSTF
• Adequate evidence shows that the harms of
screening in men older than 70 years are at least
moderate and greater than in younger men
because of increased risk of false-positive results,
diagnostic harms from biopsies, and harms from
treatment.
JAMA. 2018;319(18):1901-1913.
doi:10.1001/jama.2018.3710
60. Screening for prostate cancer
– USPSTF
• The USPSTF concludes with moderate certainty that the net
benefit of PSA-based screening for prostate cancer in men
aged 55 to 69 years is small for some men.
• How each man weighs specific benefits and harms will
determine whether the overall net benefit is small.
• The USPSTF concludes with moderate certainty that the
potential benefits of PSA-based screening for prostate
cancer in men 70 years and older do not outweigh the
expected harms.
JAMA. 2018;319(18):1901-1913.
doi:10.1001/jama.2018.3710
61. Cribado: Cáncer de próstata
Ministerio de Salud de Colombia
No se recomienda la detección
temprana organizada poblacional en
cáncer de próstata.
Se recomienda la detección temprana
de oportunidad como estrategia de
detección temprana del cáncer de
próstata en hombres mayores de 50
años, asintomáticos, que acudan a
consulta médica por diferentes
causas.
62.
63. Cribado: Cáncer de próstata
Ministerio de Salud de Colombia
Si se realiza tamización de oportunidad debe hacerse con antígeno específico
de próstata y tacto rectal en una frecuencia no inferior a 5 años y previa
explicación de los potenciales riesgos y beneficios para el paciente,
promoviendo una toma de decisiones concertada.
En los pacientes en quienes se registre un primer nivel de antígeno prostático
alterado acorde con la edad, en presencia de tacto rectal normal, se recomienda
la repetición de la prueba en el curso de los siguientes seis meses.”
64. Colonoscopia u otros exámenes para detectar
pólipos de colon y recto (o cánceres en fases
curables)
Iniciar a los 50
años
Colonoscopia
cada 10 años,
entre otros…
Hable con su
médico cuál es la
mejor estrategia
para usted…
67. Cribado: Cáncer de colon y recto
Ministerio de Salud de Colombia
• Sangre oculta en materia fecal inmunoquímica cada dos
años, o
• Colonoscopia cada diez años, cuando ésta se encuentre
disponible*.
Riesgo promedio de cancer de colon y recto
*Hasta los 75 años, según la USPSTF
68. Citología vaginal oncológica
- Y estudio de PVH -
Citología cada 3
años, desde los 21
años de edad hasta
los 29
Citología + test de
PVH cada 5 años a
partir de los 30,
hasta los 65…
69. Cribado: Cáncer cervical
Smith, R. A., Andrews, K., Brooks, D., DeSantis, C. E., Fedewa, S. A., Lortet-Tieulent, J., … Wender, R. C. (2016). Cancer screening in the
United States, 2016: A review of current American Cancer Society guidelines and current issues in cancer screening. CA: A Cancer Journal
for Clinicians, 66(2), 95–114. https://doi.org/10.3322/caac.21336
www.minsalud.gov.co
Test Categoría ACS Colombia
Citología cervicouterina Recomendación Cada 3 años, iniciando de 21-
64 años
Citología cervicouterina +
PVH ADN
Opción Cada 5 años, de 30 a 64 años
Suspender tamizaje Recomendación A partir de los 65 años, si el
tamizaje negativo en los
últimos 10 años, con el último
realizado hace menos de 5
años
PVH ADN Recomendación Cada 5 años, a partir de los
30. Realizar citología si
positivo
No se necesita tamizaje a mujeres a las que
se les realiza histerectomía total por razones
no oncológicas.
70.
71. Cribado: Cáncer cérvicouterino
Ministerio de Salud de Colombia
Si prueba de ADN-PVH positiva, se recomienda realizar prueba de triage
con citología cervicouterina.
1. En caso de que la citología cervicouterina sea anormal, se recomienda
colposcopia biopsia.
2. Si la citología cervicouterina es negativa, se debe repetir la prueba ADN-
VPH en 18 meses, y repetir el algoritmo.
72. ADN-VPH
Negativo Positivo
Citología vaginal (triage)
Negativa Positiva (anormal)
Colposcopia/biopsiaADN-VPH
18 meses
Iniciar a los 30
ADN-VPH
60 meses
Terminar a los 65 años
Cribado: Cáncer cervicouterino
Recomendaciones del Ministerio de Salud de Colombia
73. Cribado: Cáncer cérvicouterino
Ministerio de Salud de Colombia
Aunque la técnica de inspección visual es también una opción válida
recomendada por la Organización Mundial de la Salud, se considera que
esta opción debería limitarse a escenarios donde no haya acceso a mejores
tecnologías.
No se necesita tamizaje a mujeres a las que se les realiza histerectomía
total por razones no oncológicas
74. Vacuna contre el PVH
Con la vacunación
contra el PVH se
pueden evitar hasta el
70% de los cánceres
de cérvix
Iniciar desde la
niñez….
75. Tomografía de tórax en
fumadores
Sólo en
grandes
fumadores…
Cada año, a
partir de los 55
años de edad…
76.
77. Cribado: Cáncer de pulmón
Sociedad Americana del Cáncer
Recomienda considerar cribado para fumadores saludables de más
de 30 paquetes año, entre los 55 y 74 años de edad con tomografía
computada helicoidal con baja irradiación.
Para efectos de esta recomendación, se consideran también
candidatos a los exfumadores que cesaron su tabaquismo dentro de
los últimos 15 años.
78. Cribado: Cáncer de pulmón
Sociedad Americana del Cáncer
La guía es muy particular en especificar que el cribado debe realizarse en
el marco de programas de alta calidad en la detección precoz y tratamiento
del cáncer de pulmón.
También deben explicarse muy bien los alcances y limitaciones del test.
El cribado para cáncer de pulmón no es una alternativa a la cese del
tabaquismo. Este último debe ser enfatizado continuamente
80. Cribado: Cáncer de mama
Ministerio de Salud de Colombia
Recomienda realizar tamización de base poblacional organizada
mediante mamografía cada dos años en mujeres de 50 a 69 años
de edad*.
No recomiendan realizar tamización de rutina con mamografía en
mujeres de 40-49 años de edad.
*USPSTF recomienda hasta los 74 años
81. Cribado: Cáncer de mama
Ministerio de Salud de Colombia
La decisión de iniciar tamización regular con mamografía cada
dos años antes de los 50 años debe ser individual y debe tener en
cuenta el contexto del paciente incluyendo sus valores en relación
con beneficios y daños.
Se recomienda la enseñanza del autoexamen como estrategia de
concientización y autoconocimiento.
83. Cribado: Cáncer cérvicouterino
Ministerio de Salud de Colombia
Si prueba de ADN-PVH positiva, se recomienda realizar prueba de triage
con citología cervicouterina.
1. En caso de que la citología cervicouterina sea anormal, se recomienda
colposcopia biopsia.
2. Si la citología cervicouterina es negativa, se debe repetir la prueba ADN-
VPH en 18 meses, y repetir el algoritmo.
84. ADN-VPH
Negativo Positivo
Citología vaginal (triage)
Negativa Positiva (anormal)
Colposcopia/biopsiaADN-VPH
18 meses
Iniciar a los 30
ADN-VPH
60 meses
Terminar a los 65 años
Cribado: Cáncer cervicouterino
Recomendaciones del Ministerio de Salud de Colombia
85. Cribado: Cáncer cérvicouterino
Ministerio de Salud de Colombia
Aunque la técnica de inspección visual es también una opción válida
recomendada por la Organización Mundial de la Salud, se considera que
esta opción debería limitarse a escenarios donde no haya acceso a mejores
tecnologías.
No se necesita tamizaje a mujeres a las que se les realiza histerectomía
total por razones no oncológicas
86. Cribado: Cáncer de próstata
Ministerio de Salud de Colombia
No se recomienda la detección temprana organizada poblacional en cáncer de
próstata.
Se recomienda la detección temprana de oportunidad como estrategia de
detección temprana del cáncer de próstata en hombres mayores de 50
años, asintomáticos, que acudan a consulta médica por diferentes causas.
87. Cribado: Cáncer de colon y recto
Ministerio de Salud de Colombia
• Sangre oculta en materia fecal inmunoquímica cada dos
años, o
• Colonoscopia cada diez años, cuando ésta se encuentre
disponible*.
Riesgo promedio de cancer de colon y recto
*Hasta los 75 años, según la USPSTF
88. Cribado: Cáncer de próstata
Ministerio de Salud de Colombia
Si se realiza tamización de oportunidad debe hacerse con antígeno específico
de próstata y tacto rectal en una frecuencia no inferior a 5 años y previa
explicación de los potenciales riesgos y beneficios para el paciente,
promoviendo una toma de decisiones concertada.
En los pacientes en quienes se registre un primer nivel de antígeno prostático
alterado acorde con la edad, en presencia de tacto rectal normal, se recomienda
la repetición de la prueba en el curso de los siguientes seis meses.”
89. By age
Tamizaje contra
el cáncer
De acuerdo con las guías de práctica del
Ministerio de Salud de Colombia
91. De 21-29 años: Cáncer
cervicouterino
A diferencia de la ACS, el
Ministerio de Salud de
Colombia NO recomienda
tamizaje para cáncer de
cérvix uterino entre los 21-29
años de edad.
93. De 30-39 años: Cáncer
cervicouterino
Se recomienda ADN-VPH a los 30
y 35 años de edad.
Aplicar algoritmo en caso de ser
positiva.
94. ADN-VPH
Negativo Positivo
Citología vaginal (triage)
Negativa Positiva (anormal)
Colposcopia/biopsiaADN-VPH
18 meses
Iniciar a los 30
ADN-VPH
60 meses
Terminar a los 65 años
Cribado: Cáncer cervicouterino
Recomendaciones del Ministerio de Salud de Colombia
96. De 40-49 años: Cáncer
cervicouterino
Se recomienda ADN-VPH a los 40
y 45 años de edad.
Aplicar algoritmo en caso de ser
positiva.
97. De 50-65 años
Cáncer cervicouterino
Cáncer de mama
Cáncer de próstata
Cáncer de colon
Cáncer de pulmón
98. De 50-65 años: Cáncer
cervicouterino
Se recomienda ADN-VPH a los 50,
55, 60, y 65 años de edad.
Aplicar algoritmo en caso de ser
positiva.
99. De 50-65 años: Cáncer de
mama
Se recomienda realizar
tamización de base
poblacional organizada
mediante mamografía cada
dos años en mujeres de 50 a
69 años de edad.
100. De 50-65 años: Cáncer de próstata
Se recomienda la detección
temprana de oportunidad
como estrategia de
detección temprana del
cáncer de próstata en
hombres mayores de 50
años, asintomáticos, que
acudan a consulta médica
por diferentes causas.
101. De 50-65 años: Cáncer de colon
❖ Sangre oculta en materia
fecal inmunoquímica cada
dos años, o
❖ Colonoscopia cada diez
años, cuando ésta se
encuentre disponible.
102. De 50-65 años: Cáncer de pulmón
If you are age 55 or older, talk to a health
care provider about your smoking history
and whether you should get yearly low-
dose CT scans to screen for early lung
cancer.
Screening may benefit if you are an
active or former smoker (quit within the
past 15 years), have no signs of lung
cancer, and have a 30 pack-year
smoking history.
You should discuss the benefits,
limitations, risks, and potential costs of
screening.
104. Mayores de 65 años: Cáncer de
mama
Se recomienda realizar
tamización de base
poblacional organizada
mediante mamografía cada
dos años en mujeres de 50 a
69 años de edad.
105. Mayores de 65 años: Cáncer de
próstata
Se recomienda la detección
temprana de oportunidad como
estrategia de detección
temprana del cáncer de próstata
en hombres mayores de 50
años, asintomáticos, que
acudan a consulta médica por
diferentes causas.
El tamizaje de cáncer de
próstata en mayores de 70 años
no se recomienda porque causa
más riesgos que beneficios*
*Basado en las recomendaciones de la USPSTF, 2018
106. Mayores de 65 años: Cáncer de colon
❖ Sangre oculta en materia
fecal inmunoquímica cada
dos años, o
❖ Colonoscopia cada diez
años, cuando ésta se
encuentre disponible.
❖ Hasta los 75 años*
*Basado en las recomendaciones de la USPSTF
107. Ages 65 or older: Lung cancer
If you have a smoking history, talk to a
health care provider about it and whether
you should get an annual low-dose CT
scan to screen for early lung cancer.
Screening may benefit if you are an
active or former smoker (quit within the
past 15 years), have no signs of lung
cancer, and have a 30 pack-year
smoking history.
You should discuss the benefits,
limitations, risks, and potential costs of
screening.
108.
109. Appendix – Cancer screening by
age – as recommended by the
American Cancer Society
112. Ages 21-29: Cervical cancer
Starting at age 21 and through
age 29, all women should have
a Pap test done every 3 years.
HPV tests should not be done a
Pap test is abnormal.
Follow testing
recommendations even if
you've been vaccinated against
HPV.
114. Ages 30-39: Cervical cancer
Starting at age 30, women at average
risk should get a Pap test and HPV test
every 5 years (the preferred approach) or
they can continue to get only a Pap test
every 3 years.
Follow testing recommendations even if
you've been vaccinated against HPV.
You don't need testing after a
hysterectomy that removed the uterus
and cervix as long as it was done for
reasons not related to cervical cancer.
116. Ages 40-49: Cervical cancer
Starting at age 30, women at average
risk should get a Pap test and HPV test
every 5 years (the preferred approach) or
they can continue to get only a Pap test
every 3 years.
Follow testing recommendations even if
you've been vaccinated against HPV.
You don't need testing after a
hysterectomy that removed the uterus
and cervix as long as it was done for
reasons not related to cervical cancer.
117. Ages 40-49: Breast cancer
Women ages 40 to 44 should have
the choice to start annual breast
cancer screening with mammograms
if they wish to do so. The pros and
cons of screening should be
considered when making this
decision.
Starting at age 45, women should get
mammograms every year.
It's also important to know how your
breasts normally look and feel and to
report any changes to a health care
provider right away.
118. Ages 40-49: Prostate cancer
Starting at age 45, men at higher than
average risk of prostate cancer should
talk with a doctor about the
uncertainties, risks, and potential
benefits of testing so they can decide if
they want to be En tested.
This includes African-American men
and men with close family members
(father, brother, son) who had prostate
cancer before age 65.
Men with more than one close relative
who had prostate cancer before age 65
are at even higher risk and should talk
with a doctor about testing starting at
age 40
120. Ages 50-64: Cervical cancer
Get a Pap test and HPV test
every 5 years (preferred
approach) or Pap test alone
every 3 years.
You don't need testing after a
hysterectomy that removed the
uterus and cervix as long as it
was done for reasons not
related to cervical cancer.
121. Ages 50-64: Breast cancer
Women ages 50 to 54 should get
mammograms every year. Be sure
you understand the pros and cons of
breast cancer screening.
Starting at age 55, you should switch
to getting mammograms every 2
years, or you can continue to get one
every year.
It's also important to know how your
breasts normally look and feel and to
report any changes to a health care
provider right away.
122. Ages 50-64: Prostate cancer
Starting at age 50, all men
at average risk should talk
with a health care provider
about the uncertainties,
risks, and potential
benefits of testing so they
can decide if they want to
be tested.
123. Ages 50-64: Colon cancer
Everyone with
average risk,
should start testing
at age 50.
There are several
testing options.
124. Ages 50-64: Lung cancer
If you are age 55 or older, talk to a health
care provider about your smoking history
and whether you should get yearly low-
dose CT scans to screen for early lung
cancer.
Screening may benefit if you are an
active or former smoker (quit within the
past 15 years), have no signs of lung
cancer, and have a 30 pack-year
smoking history.
You should discuss the benefits,
limitations, risks, and potential costs of
screening.
125. Ages 65 or older Cervical cancer
Breast cancer
Prostate cancer
Colon cancer
Lung cancer
126. Ages 65 or older: Cervical
cancer
No testing is needed if you’ve
had regular cervical cancer
testing with normal results
during the previous 10 years.
You don't need testing after a
hysterectomy that removed the
uterus and cervix as long as it
was done for reasons not
related to cervical cancer.
127. Ages 65 or older: Breast
cancer
You should get a mammogram
every 2 years, or you can choose
to get one every year.
Be sure you understand the pros
and cons of breast cancer
screening.
It's also important to know how
your breasts normally look and
feel and to report any changes to
a health care provider right away.
128. Ages 65 or older: Prostate cancer
Overall health status, and not
age alone, is important when
making decisions about
prostate cancer testing. Men
who can expect to live at
least 10 more years should
talk with a health care
provider about the
uncertainties, risks, and
potential benefits of testing
so they can decide if they
want to be tested.
129. Ages 65 or older: Colon cancer
Testing is recommended,
and there are many testing
options.
Talk with a health care
provider about which tests
are best for you and how
often testing should be
done.
130. Ages 65 or older: Lung cancer
If you have a smoking history, talk to a
health care provider about it and whether
you should get an annual low-dose CT
scan to screen for early lung cancer.
Screening may benefit if you are an
active or former smoker (quit within the
past 15 years), have no signs of lung
cancer, and have a 30 pack-year
smoking history.
You should discuss the benefits,
limitations, risks, and potential costs of
screening.
Editor's Notes
Is breast cancer screening effective in reducing mortality?
Eight large randomized trials (sometimes broken into 9–11 separate components) have studied mammography screening in the general population, including about 600 000 women from the United States, Canada, United Kingdom, and Sweden. These studies were somewhat heterogeneous with regard to the age groups included, methods of randomization, intervals between screening, and methods of analysis. Nonetheless, meta-analyses have shown that when compared with controls, groups offered screening had a 15%–20% reduction in risk for breast cancer mortality among all age groups (6, 17). For women aged 40–59 years, the reduction in was smaller in magnitude and less statistically significant (Table 3) (17). For women aged 60–69 years, the reduction was highly significant. For women aged 70–74 years, the reduction was not significant, but far fewer women in this age group were studied. The estimated number of deaths prevented per 10 000 women screened for 10 years ranged from 3 to 21 (Table 3).
None of the individual trials showed a reduction in all-cause mortality from screening, and a meta-analysis showed a combined RR of 0.99 (95%CI, 0.97–1.00) (18). Mammography screening was protective against the development of advanced breast cancer (stage III or higher) among women aged 50 years or more (RR=0.62 [CI=0.46–0.83]). Four trials failed to show a reduction in the development of advanced breast cancer among women aged 39-49 years (RR, 0.98 [CI, 0.74–1.37]).
What is the current evidence for screening women in their 40s?
A decision to screen women in any age group involves a comparison of potential benefits to potential harms. The United States Preventive Services Task Force (USPSTF) estimates that women aged 40-49 have an 8% reduced risk of breast cancer mortality (Table 3), while the American Cancer Society (ACS) estimates a 15% reduced risk of breast cancer mortality (6, 17). The absolute number of breast cancer deaths prevented per 10,000 women screened for 10 years is estimated at 3. This is lower than the number expected for older women due to the combination of a smaller reduction in risk of breast cancer mortality and a smaller absolute risk of developing breast cancer in younger women.
Potential harms must be weighed against the small benefit of mammography in this age group, mainly the harms of false-positive results and overdiagnosis. The sensitivity and specificity of mammography are lower among women aged 40-49 years versus older women; therefore, the rate of false positives is greater for younger women. However, the cumulative risk of a false positive mammogram over a 10-year interval is similar for women aged 40-49 and 50-59 (6, 20). While overdiagnosis is a general concern, the available studies do not define whether overdiagnosis varies systematically by age group.
Statistical models show that when compared with initiating screening at age 50 years, initiating screening at age 40 years results in about 1 fewer breast cancer death averted per 1000 women screened (Table 4 ) (6, 21), with most averted deaths occurring among women aged 45–49 years at screening (22). The balance between benefits and harms for younger women is sensitive to the risk status of the woman. When compared with average-risk women aged 50–74 years undergoing biennial screening (every 2 years), women at age 40 years who have at least a 1.3-fold increase in risk still have a similar harm-to-benefit ratio. When compared with average risk women aged 50–74 years undergoing annual screening, women who have at least a 2-fold increase in risk at age 40 years still have a similar harm-to-benefit ratio (6, 21).
What are the harms?
Most concern about breast cancer screening involves false positive results and overdiagnosis. False-positive results lead to unnecessary follow-up tests and biopsies, as well as to some psychological distress. False-positive results have been shown to increase the occurrence of anxiety symptoms and psychological distress for up to 2 years after the mammogram but do not increase clinically diagnoses of depression or anxiety. To diagnose 1 case of invasive breast cancer, hundreds of women must be screened, dozens of women will have false-positive results, and 3–10 women will have a biopsy. Since early diagnosis does not always prevent death, the number of procedures needed to prevent a death from breast cancer is correspondingly higher. The cumulative risk for at least 1 false-positive result after 10 years of annual screening is 50%–60%, and the cumulative risk over 10 years of an unnecessary biopsy attributable to screening is 7%–10% (6, 16).
Overdiagnosis is early diagnosis of cancer that would never have progressed to clinical importance in the absence of screening. Although many overdiagnosed cases are ductal carcinoma in situ, it is now believed that some invasive cancers represent overdiagnosis as well. Overdiagnosis is a serious issue because the patient is subjected to the harms of treatment without any benefit, since the tumor would not have caused the patient harm if not detected. Once the cancer is diagnosed, there is no way to determine whether it is a case of overdiagnosis; the evidence showing overdiagnosis comes from studying the number of cancers diagnosed in screened women compared with those diagnosed in similar but unscreened women. Estimates of the percentage of overdiagnosed cancers are wide-ranging, but the best data estimate that about 10%–20% of breast cancer cases diagnosed in screened women represent overdiagnosis (6, 16).
Another potential harm of screening mammography is radiation exposure. Increased risk for radiation-induced cancer has been demonstrated in studies of women who have had therapeutic chest irradiation for Hodgkin lymphoma and/or frequent chest radiography and computed tomography. A recent estimate of the number of deaths due to radiation-induced cancer from digital mammography screening is 0.4 –1.2 per 10 000 women screened over a lifetime (6, 19).
When should average-risk patients stop screening?
The incidence of breast cancer increases with age and remains substantial beyond 80 years; 26% of breast cancer deaths are attributable to a diagnosis after age 74 years (22). Few women aged 70-74 years and no women older than 74 years were included in the randomized trials of screening mammography, so little direct evidence exists regarding the benefit of screening after age 69 years. Observational studies and modeling studies estimate fewer breast cancer deaths and fewer harms for women who continue biennial screening for 10 years during their 70’s rather than stopping screening at age 69 years (6, 21). Such studies also suggest that it is cost-effective to continue biennial screening until the remaining life expectancy is about 10 years, which is age 80 for US women of average health (23). Therefore, it may be reasonable for healthy women to undergo screening through their 70’s. Women with severe comorbid illness may elect to conclude screening even earlier than age 70 (21, 24). Conducting a formal assessment of remaining life expectancy can lead to an uncomfortable discussion, so instead we advise women aged 80 and older that the benefit of screening is generally low.
