Cancer Flashcards
How do we determine which cancers we screen for and when do we screen for them?
-Asymptomatic
-Clinically relevant: high incidence, mortality, morbidity
-Obvious preclinical stage before symptoms present
-Effective treatment for early-stage cancer
=Improved outcome when treated at an early stage
=Shortening disease duration
=Decreasing the severity of the disease
-Must be cheap, safe, simple, minimally invasive, widely available, culturally acceptable
What types of screening tests are available?
- Imaging, mammogram
- Laboratory tests, PSA
- Exfoliative cytology, Pap smear
- Endoscopy, colonoscopy
- Physical examinations
- Self examinations???
What are some hallmark symptoms of cancer?
- Unexplained weight loss*
- Fever, night sweats*
- Extreme fatigue
- Persistent pain
- Skin changes
- Change in bowel/bladder function
- Nagging cough/hoarseness
- Unusual bleeding/Discharge
- Lumps/thickening in breast
- Difficulty swallowing
When should we start screening high-risk patients?
If family history but no genetic predisposition syndrome, start screening went patient is 10 years younger than age affected family member diagnosed with cancer
Which cancers the highest incidence? Which cancers have the highest mortality?
- Highest incidence: breast and prostate
- Highest mortality: lung and bronchus
What are some red flags for cancer predisposition syndromes?
Cancer in 2 or more close relatives on same side family
Early age at diagnosis
Multiple primaries in the same individual
Bilateral cancers
Constellation of tumors associated with a specific cancer syndrome (ie. breast and ovarian)
Presence of congenital anomalies or syndrome associated benign lesions
Family History:
Paternal and maternal, 2-3 generations
Dynamic and evolve over time
De novo
Those with the BRCA1 gene are at a high risk for which cancers?
Breast cancer 50% to 85%, often and early age of onset
Second primary breast cancer 40% to 60%
Ovarian cancer 15% to 45%
Slightly increased risk of uterine and cervical cancer
Those with the BRCA2 gene are at a high risk for which cancers?
Breast cancer 50% to 85%
Ovarian cancer 10% to 20%
Male breast cancer 6%
What are some general risk factors for developing breast cancer?
Benign breast disease -Proliferative without atypia: RR 1.5-2.0 -Atypical hyperplasia: RR 4.0-5.0 -Atypia with family history: RR 11 Other cancers -Especially breast, and ovarian Previous therapeutic thoracic radiation therapy -2nd or 3rd decade - 56 fold increase
What are some reproductive risk factors for developing breast cancer?
Early menarche (<9 years): RR 1.2
Late menopause (>55 years): RR 2.0
Full-term pregnancy (> 30 years of age): RR 2.0
Nulliparity: RR 1.4
HRT: RR 2
OCP: RR 0.9 - Reduces risk of breast cancer
What are some social history related risk factors for developing breast cancer?
Obesity
Pre menopause: RR 0.6 - 1
Post Menopause: RR 1.16 - 1.74
ETOH
1-2/day: RR 1.04 - 1.19
2-4/day: RR 1.21 – 1.41
Smoking
Fruits/Vegetables
Exercise decrease risk
What are some family history related risk factors for developing breast cancer?
1st Degree: RR 2.5
2nd Degree: RR 1.5
Genetic predisposition syndrome
What factors are incorporated into the Gail model for assessing breast cancer risk?
Age Reproductive History Benign Breast Disease History Atypical Hyperplasia Breast Cancer in Mother or Sisters Race in Modified Model
What factors are NOT incorporated into the Gail model for assessing breast cancer risk?
Other Cancers 2nd Degree Relatives Paternal History Age at Diagnosis in Relatives Modifiable Risks
What do the Gail model results tell you? How well does it assess risk?
Five year risk of developing breast cancer
Lifetime risk of developing breast cancer
May underestimate risk as it does not take everything into account
What risk factors does the Clause model focus on?
Family history
Age
What are some lifestyle risk reduction strategies for those at average risk of developing breast cancer?
Lean, Healthy Weight Over a Lifetime
-BMI: 18.5-25
Diet -Minimum Calories =Men: 1200-1600 =Women: 1000-1200 -Plant Based -Lean Protein (Limit Animal Fat)
Exercise
-30 Minutes/Day
Alcohol
- Maximum: 1 Drink/Day
- CAGE
What are some reproductive risk reduction strategies for those at average risk of developing breast cancer?
Avoid/Limit HRT
- Estrogen and Progestin
- Lowest Dose
- Shortest Time Needed
Pregnancy
Breast Feeding
What are some risk reduction strategies for those at high risk of developing breast cancer?
Chemoprevention
- Tamoxifen (Nolvadex)
- Raloxifen (Evista)
Preventive Surgery -Prophylactic Mastectomy -Prophylactic Oophorectomy =Ideally between ages 35-40 =Upon completion of childbearing
How often should women with average risk get mammograms done?
Annually age 45 to 54
Biennial or annual age 54+
Opportunity for annual age 40 to 44
No upper age limit, as long as good health status, life expectancy 10+ years, and willing to have diagnostic and therapeutic procedures
How often should women with high risk get mammograms done? Which women are considered high-risk? What other tests should be considered?
Starting age 30
Annual mammogram
Addition of annual MRI
CBE
Known or likely BRCA mutation carriers
Untested but 1st degree relative w/ BRCA mutation
Approximately 20% to 25% or greater lifetime
risk of breast cancer
Radiation to chest for Hodgkin disease between ages 10-30
Li-Fraumeni syndrome, Cowden syndrome, or Bannayan-Riley-Ruvalcaba syndrome, or have first-degree relatives with one of these syndromes
What is the clinical presentation of breast cancer?
Painless lump in the breast: -Solitary, unilateral mass -Solid, irregular -Non-mobile Stabbing or aching pain
Less common symptoms are:
- nipple discharge,
- retraction,
- dimpling,
- inflammatory symptoms
What are some risk factors for developing over in cancer?
Age:
55-64 yrs
Median Age is 63
Race
Reproductive factors: Nulliparity/Low parity Early Menarche (before 12) Late Menopause (after 50) Late Full-term Pregnancy (> 35) Infertility HRT > 5 years Protective: -Use of OCPs >5 years -1st Pregnancy <25 -Breast Feeding
PMH/PSH
Breast Cancer
Endometrial Cancer 10%
Social history
Obesity
High Fat Diet
Talcum Powder
Familial history
5% if 1 First Relative
7% if 2 First Relatives
Hereditary Non-Polyposis Colon Cancer Syndrome (HNPCC) puts you at risk for what cancers?
Increased Risk of Colorectal Cancer
Increased Risk of Gastric Cancer
40-60% Chance of Developing Endometrial Cancer
10-15% Chance of Developing Ovarian Cancer
At what age should women with high-risk of developing ovarian cancer begin screening? Which women are considered high-risk? What other tests should be considered?
High risk: 2 1st degree relatives, BRCA and HNPCC mutations
Starting age 25 Pelvic exam Trans-vaginal ultrasound CA 125 Annual until childbearing completed or at least age 35 and undergo prophylactic bilateral oophorectomy (NIH Consensus Conference, JAMA 1994) Transvaginal and CA 125 at discretion of provider starting age 30-35 (NCCN)
What are some early clinical presentations of ovarian cancer?
Daily Symptoms Lasting More Than a Few Weeks -Abdominal Bloating -Difficulty Eating or Early Satiety -Urinary Urgency -Pelvic or Abdominal Pain Increased Abdominal Size Pain During Intercourse Change in Bowel/Bladder Habits Indigestion, Dyspepsia Early Satiety Back Pain Palpable Adnexal Mass -In Pre-Menopausal Women – 5% Represent Cancer -In Post-Menopausal Women - Requires Surgical Exploration
What are some late clinical presentations of ovarian cancer?
Ascites Pleural Effusion Anorexia Nausea/Vomiting Masses -Abdominal -Pelvic -Ovarian -Omental
