Cancer Screening

Question 1

General lifestyle recommendations in prevention of all cancers include:
8

Answer 1

1. Avoid tobacco
2. Be physically active
3. Maintain a healthy weight
4. Limit alcohol
5. Avoid excess sun
6. Eat a diet rich in fruits, vegetables, and whole grains and low in saturated/trans fat
7. Protect against sexually transmitted infections
8. Get regular screening for breast, cervical, and colorectal cancer

Question 2

PRINCIPLES OF SCREENING

5

Answer 2

1. Disease has high prevalence
2. Disease has serious consequences
3. Detectable preclinical phase
4. Treatment for presymptomatic disease is more effective than after symptoms develop
5. Positive impact on clinical health outcomes:
   - Early detection reduces cancer mortality

Question 3

Which cancers are largely asymptomatic in the early stages?

3

Answer 3

1. Colorectal,
2. breast and
3. cervical cancer
   - They have at least a 90% 5-year survival rate if detected and treated when the cancer is still localized

Question 4

1. What is the leading cause of death from gynecologic malignancy in the US?
2. Survival is much improved for earlier-stage disease. However, what is the issue with this?

Answer 4

1. Ovarian cancer

2. most cancers have spread beyond the ovary at the time of diagnosis.

Question 5

1. Describe the realtionship between annual pelvic exams and mortality from ovarian cancer?
2. Ovarian tumors can be detected during what?
3. although early stage tumors are rarely found due to what?
4. Tumors detected by bimanual pelvic examination are usually what?

Answer 5

1. There is no evidence that annual pelvic examination reduces mortality from ovarian cancer
2. bimanual pelvic exam
3. to the deep anatomic location of the ovary
4. at an advanced stage and associated with a poor prognosis

Question 6

1. screening with annual ____and ______ in postmenopausal women has shown no decrease in mortality from ovarian cancer
2. Women with what (3) should be screened with a combination of CA 125 and TVUS?
3. Initiation at age what for screenning?

Answer 6

1. CA 125, TVUS
2. • familial ovarian cancer syndrome
   • or BRCA genes,
   • who have not undergone prophylactic oophorectomy
3. 35 years or 5 to 10 years earlier than the earliest age of first diagnosis of ovarian cancer in the family.

Question 7

1. BRCA1 and BRCA2 mutations are inherited as ________ _________, highly penetrant, germline mutations that are associated with an inherited susceptibility to breast and ovarian cancer.
2. BRCA1 carriers – cumulative risk by age 70:
   •Breast cancer risk ___%
   •Ovarian cancer risk ___%
   •Contralateral breast cancer ___%
3. BRCA2 carriers – cumulative risk by age 70:
   •Breast cancer risk ___%
   •Ovarian cancer risk ____%
   •Contralateral breast cancer ___%

Answer 7

1. autosomal dominant
2. 60
   59
   83
3. 55
   16.5
   62

Question 8

OVARIAN CANCER SCREENING RECOMENDATIONS

1. The USPSTF recommends what?
2. The ACS recommends what?
3. ACOG recommends what?
4. What do these recommendations not include?

Answer 8

1. The USPSTF recommends against screening for ovarian cancer in women.
2. The ACS recommends against screening for ovarian cancer in women.
3. ACOG recommends annual pelvic exam in all patients aged 21 and older
4. ***Does not include women with known BRCA mutations

Question 9

PRINCIPLES OF SCREENING for ovarian cancer

4

Answer 9

1. Disease has high prevalence
   - Every year about 22,000 women will receive a diagnosis of ovarian cancer.
   - A woman’s risk of getting ovarian cancer during her lifetime is about 1 in 75.
2. Disease has serious consequences
   - Every year about 14,180 women will die from ovarian cancer.
   - Ovarian ca ranks 5th in cancer deaths among women, accounting for more deaths than any other cancer of the female reproductive system.
3. Detectable preclinical phase ???
   - Expensive and invasive testing not shown to be specific or sensitive enough to accurately diagnose ovarian CA early enough
4. Positive impact on clinical health outcomes:
   - Annual pelvic exams, CA-125, and TVUS DO NOT decrease mortality from ovarian cancer

Question 10

Prevention of Ovarian cancer?

4

Answer 10

1. Oral contraceptives
2. Gynecologic surgery
3. Pregnancy
4. Breastfeeding

Question 11

Cervical cancer was once one of the most common causes of cancer death for American women.
But over the last 30 years, the cervical cancer death rate has gone down by more than 50%.
1. The main reason for this change was what?

2. This screening procedure can find what? 2

Answer 11

1. the increased use of the Pap test.
2. changes in the cervix before cancer develops.
   It can also find cervical cancer early − in its most curable stage.

Question 12

CERVICAL CANCER SCREENING RECOMMENDATIONS
1. USPSTF, ACS, and ACOG Recommend?

2. How often from that age?
3. Then Beginning at age 30? 2
4. May stop when?

Answer 12

1. All women should begin cervical cancer screening at age 21 unless they have HIV or are immunocompromised
2. From 21-29 cytology only every 3 years
3. • Cytology every 3 years
   • Co-testing cytology & HPV testing every 5 years
4. May stop after 65 if adequate screening in the past 10 years w/ 2 negative screens/If not getting adequate screening wait until 70-75YO

Question 13

In what situations would you get a colposcopy?

2

Answer 13

1. After HPV pos and had a HPV pos test one year later

2. HPV DNA testing if its HPV 16 or 18

Question 14

High-Risk Groups
Those who need more frequent screening (usually annual):
4

Answer 14

1. Patients with HIV infection
2. Patients who are immunosuppressed (SLE)
3. Those who had in utero DES exposure
4. Women who have been treated for CIN2, CIN3 or cervical cancer

Question 15

1. Women who have had a total hysterectomy (removal of the uterus and cervix) may also choose to stop having Pap tests, unless what?
2. Women who have had a hysterectomy without removal of the cervix should go about screening how?
3. Women who have had their cervix removed for reasons other than cervical cancer should go about pap screening how?

Answer 15

1. the surgery was done as a treatment for cervical cancer or pre-cancer.
2. should continue to have Pap tests per recommendations
3. DO NOT need pap smears

Question 16

Cervical Cancer Prevention?

4

Answer 16

1. Gardasil!!!
2. Avoiding exposure to HPV
3. Not smoking
4. Pap smear (detects pre-cancerous changes be before it becomes invasive cancer)

Question 17

Breast Cancer:

Majority of cancers are diagnosed as a result of what?

Answer 17

an abnormal screening study

Question 18

Primary risk factors for breast cancer? 2

Answer 18

1. Gender: predominantly in females

2. Age: about 85% of breast cancers occur after women reach 50 years of age

Question 19

Screening Tools for breast cancer

3

Answer 19

1. Mammography remains the mainstay
2. US is usually used to follow up abnormalities on a mammogram
3. MRI is emerging for screening high risk patients in combination with mammography

Question 20

At what age do the following organizations reccommend breast cancer screening:

1. ACS?
2. USPSTF?
3. ACOG?

Answer 20

1. —ACOG recommends annual mammogram after age 40
   (Age 40-44….Neither the ACS nor the USPSTF now recommends regular mammography for women age in this age group)
2. Age 45-49….The ACS, but not the USPSTF, recommends mammograms every year
3. Age 50-54….The ACS recommends mammograms every year, but the USPTSF recommends mammograms every two years.

Question 21

All guidlines recommend mammograms every two years from what ages?

Answer 21

55-74

Question 22

Breast Cancer CBE Screening Recommendations
1. ACOG recommends? 2

2. ACS?
3. USPSTF recommendation? 2
4. All three organizations recommend WHAT?

Answer 22

1. • CBE be performed annually in women aged 40 years and older
   • CBE for women 21-39 every 1–3 years
2. does not recommend regular CBE and self breast exam
3. • Recommends against teaching breast self-examination (BSE)
   • States evidence is insufficient to assess the additional benefits and harms of clinical breast examination (CBE)
4. patient breast self awareness and that women report changes in their breasts to the their providers

Question 23

Clinical Breast Exam (CBE)
Proper Technique?
4

Answer 23

1. Flatten breast tissue against the chest
2. Examine in vertical strips
3. Make circular motions w/ pads of the middle 3 fingers
4. Examine each breast w/ 3 different pressures for at least 3 minutes

Question 24

When To Stop Mammography

2

Answer 24

1. Some recommendations are to stop at age 70 – 75
   - -It depends! Every patient is different
2. Other groups suggest that as long as a woman has a life expectancy of at least 10 years breast cancer screening with mammography may be continued

Question 25

COLORECTAL CANCER
Assess Risk: Ask the following questions? 3
(starting at what age?)

Answer 25

Starting at age 20 and every 5 years thereafter

1. Have you ever had colorectal cancers or an adenomatous polyp?
2. Have you had inflammatory bowel disease?
3. Have any family members had CRC or an adenomatous polyp? If so, how many, were they 1st degree relatives and at what age was the cancer or polyp diagnosed?

If there is ONE yes answer—that patient may be at risk and needs further evaluation**

Question 26

USPSTF, ACS recommendations

Average risk men and women 50 years of age to 75** years of age: When should the following be done?

1. Fecal Occult Blood Test (with a sensitive test)?
2. Flexible Sigmoidoscopy?
3. Colonoscopy?
4. Virtual colonoscopy?

Answer 26

1. Fecal Occult Blood Test (with a sensitive test)
   - Annually, beginning at age 50
2. Flexible sigmoidoscopy
   -Every 5 years, beginning at age 50
   + sensitive FOBT every 3 years
3. Colonoscopy**
   Every 10 years, beginning at age 50
4. Virtual colonoscopy every 5 years

Question 27

1. A fecal occult blood (FOBT) test finds blood in the stool (__ samples usually tested)
2. Which fecal occult test is more sensitive?
3. A pos FOBT warrents what?

Answer 27

1. 3
2. • Stool guaiac (low sensitivity)
   • Immunochemical stool tests (Increased sensitivity, without loss of specificity)
3. • FOBT always warrants a colonoscopy.

Question 28

Advantage of Flexible Sigmoidoscopy?

Risks? 2

Disadvantages? 2

Answer 28

1. Biopsies can be taken through the scope during a flexible sigmoidoscopy exam

A flexible sigmoidoscopy exam poses few risks:

1. Bleeding from the site where a tissue sample (biopsy) was taken
2. A tear in the colon or rectum wall
3. Cannot see entire colon
4. Proximal lesions may not be seen.

Question 29

Colonoscopy is what?

Answer 29

the endoscopic exam of the colon AND the distal part of the small bowel with a fiber optic camera on a flexible tube passed through the rectum

It may provide a visual diagnosis (e.g. ulceration, polyps) and allows the opportunity for biopsy or removal of suspected lesions

Question 30

Complications of colonoscopy? 2

Answer 30

1. Bleeding from the site where a tissue sample (biopsy) was taken
2. A tear in the colon or rectum wall

Question 31

SCREENING FOR HIGH RISK POPULATIONS

1. 1st degree relative with colon CA or adenomatous polyp diagnosed at age less than 60, or two 1st degree relatives with colon CA at any age
   - Screening colonoscopy when? 2
   - Repeat when?
2. Familial Adenomatous Polyposis (FAP)
   - screening starting when?
3. Hereditary nonpolyposis colon cancer (HNPCC)
   - Screening when? 2 How often?

Answer 31

1. • age 40 or 10 years prior to earliest family diagnosis
   • Repeat screen every 5 years
2. Annual sigmoidoscopy starting age 10-12
3. • Colonoscopy q1-2 years beginning age 20-25 or
   • 10 years prior to earliest CA diagnosis in family

Question 32

History of Adenomatous Polyps:
1. –Surveillance based what? 2

2. When would you repeat colonoscopy in 3 years? 3
3. When would you repeat colonoscopy in 5 years?

Answer 32

1. on pathology and number of adenomas at most recent prior colonoscopy
2. • Any adenoma with high grade dysplasia or
   • villous features, or
   • multiple adenomas (≥3)
3. 1-2 small (less than 1cm) tubular adenomas with low grade dysplasia only

Question 33

What is a virtual colonoscopy?

Answer 33

CT colonography (“virtual colonoscopy”) — Computed tomography colonography (CTC, sometimes called “virtual colonoscopy”) is a test that uses a CT scanner to take images of the entire bowel. These images are in two- and three-dimensions, and are reconstructed to allow a radiologist to determine if polyps or cancers are present

Question 34

1. Whats the major advantage of visual colonoscopy?

2. Disadvantage?

Answer 34

1. The major advantages of CTC are that it does not require sedation, it is non-invasive, the entire bowel can be examined, and abnormal areas (adenomas) can be detected about as well as with traditional (optical) colonoscopy
2. However if an abnormality is detected then the patient must have a colonoscopy to obtain tissue or remove a polyp

Question 35

What are the screening tests for prostate cancer? 2

Answer 35

1. Digital rectal examination (DRE)

2. Prostate specific antigen (PSA)

Question 36

DIGITAL RECTAL EXAMINATION (DRE)

1. Can detect tumors in the _________ and _______ aspects of the prostate—only 85% of tumors are peripheral
2. Can not detect those that are not ________?

Answer 36

1. posterior, lateral

2. peripheral

Question 37

A negative examination ________ change the likelihood of a clinically significant prostate cancer?

Answer 37

does not

No controlled studies have shown a reduction in the morbidity or mortality of prostate CA when detected by DRE at any age!

Question 38

PSA SCREENING: TEST ISSUES
1. Levels of ___ ng/ml or less have typically been considered to be normal

Results from the Prostate Cancer Prevention Trial show that prostate cancer is not rare even in these men:

2. 27% cancer in those with PSA _____?
3. 24% in those with PSA _____?
4. 17% in those with PSA ______?
5. 10% in those with PSA ______?
6. 7% in those with PSA up to ___

Answer 38

1. 4.0
2. 3.1 to 4.0
3. 2.1- 3.0
4. 1.1 to 2.0
5. 0.6 to 1.0
6. 0.5

Question 39

Positive predictive value:
1. For PSA levels between 4.0 – 10.0 ng/mL—___% of men will have prostate CA:

2. Nearly 75% of cancers detected in this “gray zone” are what?
3. There is a high false-positive rate which leads to many what?
4. For PSA levels > ___ ng/mL 42–64% will have prostate CA

Answer 39

1. 25
2. organ confined & potentially curable
3. unnecessary biopsies
4. 10

Question 40

PSA SCREENING: TEST ISSUES

Potential benefits of prostate cancer screening include? 3

Potential risks of prostate cancer screening include? 3

Answer 40

1. Screening can detect cancers early
2. Treatment for prostate cancer is more effective when it is found early
3. Five-year survival in men with localized prostate cancer or just regional spread is 100% compared with 32% in those with distant metastases
4. False positive test results that lead to further tests and can cause anxiety ($$$, invasive)
5. Potential side effects, such as infection, from biopsies
6. Treatment of some prostate cancers that may have never affected a man’s health even if left untreated

Question 41

Prostate Cancer Screening recommendations

1. USPSTF?
2. ACS?
3. AUA?

The greatest benefit of screening appears to be in men ages _______ years.

Answer 41

1. USPSTF:
   Recommends against PSA based screening for prostate cancer.
2. ACS:
   Recommends that men have a chance to make an informed decision with their health care provider about whether to be screened for prostate cancer.
3. AUA:
   The Panel does not recommend routine screening in men between ages 40 to 54 years at average risk.
   For men younger than age 55 years at higher risk (e.g. positive family history or African American ), decisions regarding prostate cancer screening should be individualized.
   AUA strongly recommends shared decision-making for men age 55 to 69 years that are considering PSA screening, and proceeding based on a man’s values and preferences.

55 to 69

Question 42

1. Complications of prostate cancer treatment? 3

Answer 42

1. • Sexual dysfunction
   • Urinary incontinence
   • Bowel dysfunction

Question 43

1. In most men the discussion should begin at the age of ___?
2. Though not with men who have a comorbidity that limits their life expectancy to less than ____?
3. The PSA level can then be checked every ___years

Answer 43

1. 50
2. 10 yrs
3. 2-4

Question 44

Screening MAY be discussed at age 40 for? 3

When to stop screening?

Answer 44

1. African American men
2. Men with a family history of prostate CA, particularly in relatives less than age 65
3. Men who are known to have the BRCA1 or BRCA2 mutation

When a man has a less then 10-year life expectancy

Question 45

LUNG CANCER SCREENING RECOMMENDATIONS:

1. Recommends annual screening for lung cancer with low-dose computed tomography (LDCT) in adults aged_______ years who have a ___ pack-year smoking history and currently smoke or have quit within the past ___ years.
2. Screening should be discontinued once a person has not smoked for ___ years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery.

Answer 45

1. 55 to 80, 30, 15

2. 15

Question 46

ACS Lung cancer screening:
1. Screening guidelines for people at high risk?
3

2. Recommend screening? 3

Answer 46

1. 55-74 years of age
2. In fairly good health
3. Have at least a 30 pack year hx and are still smoking or have quit within the last 15 years
4. Method: LDCT scan**
5. Location: center that can accurately do the scans and have the expertise to interpret and advise the patient
6. RISK—unnecessary biopsies and even partial removal of a lung

Question 47

What are the downsides of NLST?

2

Answer 47

Downside:

• 20% false positive rate,
• 2% suffered complications

Question 48

LUNG CANCER:
Principles of Screening

5

Answer 48

1. Disease has high prevalence:
   (2nd most common cancer in the US)
2. Disease has serious consequences: #1 cause of cancer mortality for both men & women in US
3. Detectable preclinical phase :
   (LDCT annually in high-risk patients successfully detects earlier stages)
4. Treatment for pre-symptomatic disease is more effective than after symptoms develop:
   (when detected in Stage I, improves 5-year survival from 15% to 40-70%)
5. Screening reduces cancer mortality: LDCT 20% decrease in mortality

Question 49

SKIN CANCER

The effectiveness of screening depends upon multiple factors?
4

Answer 49

1. Whether the clinician performing the examination can identify early stage disease
2. Whether the pathologist can accurately diagnose and histologically stage the disease
3. Whether the tumor is identified at a stage where treatment would be effective
4. Whether the tumor identified by screening would become clinically meaningful to the patient in his or her lifetime. Identifying a disease that would not impact a person’s quality or duration of life is referred to as “overdiagnosis.”