Cancer Screening Flashcards
Describe the carcinogenic pathway
- initiation
- inherited acquired DNA change, immature response - promotion
- additional exposures, DNA mutations, epigenetic changes, immune response, pre-malignant dx, early malignant dx - progression
- additional exposures, DNA mutations, epigenetic changes, immune response, symptomatic dx
What is a risk factor?
characteristic associated with statistically significant likelihood of developing particular disease in a particular time
-risk increase with dose/exposure
Probability calculation
- average v high risk individual (or group)
- use of multifactorial risk calculators, if available
What are risk reduction interventions and why should/shouldn’t consider them?
- goal is to decrease cancer susceptibility, stop carcinogenesis, ideally evidence-based, not available for all cancers, is the individual willing and or able to follow?
- lifestyle modification, vaccination, chemoprevention, prophylactic surgeries
- do benefits exceed risks? Accept more risk from interventions if individual or group is higher risk for disease
What disease-specific characteristics are necessary to be considered for screening?
Early detection of sub-clinical disease
Asymptomatic
Disease
Be clinically relevant
High incidence, mortality, morbidity
Has an obvious pre-clinical stage before symptoms present
Has an effective treatment for early stage cancer
Improved outcome when treated at early stage
Shortening disease duration
Decreasing the severity of the disease
What are screening test examples and what characteristics must they have?
Cheap, simple, safe, minimally invasive, widely available, culturally acceptable
Includes Imaging Laboratory tests Exfoliative cytology Endoscopy Physical examinations Self examinations
What characteristics must a patient have to be considered for screening?
If positive
Likely to undergo treatment
Has access to care
Patients should know
primary risk reduction strategies
symptoms of cancers
What are symptoms of cancer?
unexplained weight loss extreme fatigue skin changes nagging cough/hoarseness lump thickening in breast fever, night sweats persistent pain change in bowel/bladder unusual bleeding/discharge difficulty swallowing
What are general screening recommendations for high risk patients?
Generally beginning screening earlier
FH but no genetic predisposition syndrome, start screening when patient 10 years YOUNGER than age affected family member diagnosed with cancer
Perform more often than for average risk patients
May do more invasive, riskier screening
What considerations are there of screening older adults for cancer?
“Screening in the elderly is not associated with a survival advantage”
Elderly frequently have life limiting co-morbid medical conditions
More indolent nature of some cancers in the elderly
“Die with or die of cancer” conundrum
But studies have not always Included older adults Adjusted for differences in frailty Accounted for groups at increased risk Addressed impact of screening on QOL, suffering, or functionality
More likely to be diagnosed at advanced stage than younger counterparts
** Never screened **
Many will benefit from treatment
But with advanced stage, more extensive treatments
Aging population, increased cancer burden, costs
Breast cancer lifetime risk
12.4%
age 40-70
median age 55
Most common cancers based on sex
- most likely to die, lung for both
- prostate most likely “men”
- breast most likely “women”
- colon is next for both
Discuss family history and risk assessment for screening
Family History If 1st degree relative with cancer Especially if diagnosed at younger age generally start screening for that cancer 10 yrs before the age of affected person when diagnosed Breast Cancer Family history First degree relative: RR 2.5 Second degree relative: RR 1.5
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
Discuss BRCA 1 lifetime risk
Breast cancer 50%-85% (often early age at onset)
Second primary breast cancer 40%-60%
Ovarian cancer 15-45%
Slightly increased risk of Uterine and Cervical cancer
Possible increased risk of other cancers:
Prostate Colon
Male breast cancer Fallopian tube
Pancreatic Gastric
Discuss BRCA2 lifetime risk
Breast Cancer (50%-85%) Male Breast Cancer (6%) Ovarian Cancer (10%-20%) Increased risk of other cancers: Prostate Laryngeal Pancreatic Melanoma Stomach
PMH/PSH risk for breast ca
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
Reproductive risk factors for breast ca
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
Social history risks for Breast ca
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
Family history risk for breast ca
1st Degree: RR 2.5
2nd Degree: RR 1.5
Genetic predisposition syndrome
What is the GAIL model for Breast cancer?
5 year and lifetime risk, in women >35 1.7% = high risk
includes: age, reproductive history, benign breast disease history, atypical hyperplasia, breast cancer in mother or sisters, race in modified model
does not include: other cancers, 2nd deg relatives, paternal history, age at diagnosis in relatives, modifiable risks
What is the Claus Model?
Predictive model for breast cancer risk. predominantly based on family history (and number of family members) and age.
-20% or greater lifetime risk of breast cancer is high risk
Breast cancer risk reduction for average risk patients
- lean healthy weight 18.5-25 BMI
- diet (plant based); men 12-1600, women 10-1200, lean protein
- 30 minutes exercise daily
- ETOH max 1 drink per day, CAGE
- reproductive
- avoid/limit HRT, lowest dose, shortest time needed - pregnancy
- breastfeeding
Breast cancer risk reduction for high risk patients
- chemoprevention
- tamoxifen (Nolvadex)
- raloxifen (Evista) - Preventive Sx
- prophylactic mastectomy
- prophylactic oopherectomy (35-40 age, upon completion of childbearing)
Average risk mammogram recommendations
Mammography Regular, annually age 45-54 -biennial or annual >54
-opportunity for annual age 40-44
No age upper age limit
– good health status,
life expectancy >10 years
Willing to have diagnostic and therapeutic procedures
What are the birads scores mean?
Category 0: need additional imaging evaluation
Category 1: negative- no findings to comment on.
Category 2: benign finding - finding not consistent with mammographic evidence of malignancy.
Category 3: probably benign finding–short-term interval follow-up suggested to establish its stability over time.
Category 4: suspicious abnormality–biopsy should be considered
Category 5: highly suggestive of malignancy–appropriate action should be taken
