Oncological alertness Flashcards
What are the advantages of opportunistic screening
Simple, cheap to administer. Not dependent on patient compliance. Reach people who do not come only for preventative measures.
What are the disadvantages of opportunistic screening?
Does not cover 100%. Time not protected. Patient may be less receptive when ill.
How is cancer therapy improving?
- Finance, dx and tx
- Modern techniques tharapy availability
- Staff knowledge, awareness, experience
- organization of health care system
- early detection
What is early cancer detection based upon ?
Screening and oncological alertness
What is the definition of oncological alertness?
Patient: awareness of cancer sx and immediate visit to the doctor when developed
Doctor: Active cancer seeking through standard Dx procedures in all cases of non-specific sx, which could suggest cancer
What are the general sx that may suggest cancer?
- recurrent inf
- fever of unknown origin
- unexplained loss of weight / appetite
- tiredness, weakness
- N/V
- chronic pain
- bleeding, anemia, unexplained bruised
What are the organ specific symptoms suggesting cancer?
- palpable tumor
- lymphadenopathy
- hematuria, GI bleed, abnormal PV (?) bleed
- chronic unexplained cough
- hoarseness
- GI: diarrhea, constipation, difficulty in swallowing
- Indrawn breast nipple
- Skin: chronic wounds, change in appearance / color / size
CAUTION mnemonic
What are the NICE guidelines regarding cancer?
Suspected cancer, recognition and referral advice
NICE lung ca - refer via ca pathway
- CXR finding suggestive of ca
- aged >40y w unexplained hemoptysis
NICE lung ca - offer urgent CXR
- age >40y w following sx that are unexplained (if smoker/ ex-sm/ asbestos exp), 1 sx is needed, if never smoked 2 sx are needed:
1. Cough
2. Fatigue
3. Shortness of breath
4. Chest pain
5. Weight loss
6. appetite loss
NICE lung ca - consider urgent CXR within 2w
Aged > 40 w
- Persistent/ recurrent chest inf
- Finger clubbing
- Supraclavicular / persistent cervical lymphadenopathy
- Chest signs consistent w lung ca or pleural disease
- Thrombocytosis
What are NICE recommendation for children w unexplained visible hematuria?
Very urgent referral within 48h, Wilms?
NICE for 45 or older w unexplained hematuria + w/o UTI or persistent/ recurrent hematuria after treated UTI?
Cancer pathway referral within 2 weeks, bladder or renal
NICE for women 55 or older w visible hematuria + 1) unexplained vaginal discharge or 2) low Hb or 3) thrombocytosis or 4) high blood glucose?
Direct access transvaginal US to assess endometrial thickness
NICE for men w visible hematuria
Consider DRE and PSA
> 60 y w unexplained non visible hematuria + either dysuria or FBC shows raised WCC
Cancer pathway referral (within 2w) -> bladder
What is the incidence of prostate cancer?
- 3rd leading cause of cancer death
- lifetime risk of dx is 15%, risk of death 2-3%
- 70 % of men aged 70 have occult prostate ca
- older age increase likelihood of prostate ca but decrease likelihood of death from it due to increased mortality from other causes
What are the cancer screening for prostate ca
- DRE: sens 59% and PPV 5-30%
- PSA > 4 ng/ml have a sens of 70-80% and PPV 40%
- cancer is also found w PSA levels <0,5ng
- randomised trials increase dx frequency bu no difference in prostate cancer mortality
What is the prevalence of lung cancer?
Leading cause of cancer death. Cigarette smoking responsible for 85% of cancer
What are the screening methods for lung cancer?
- CXR have 60% sens
- CT scan have 94% sens
- number needed to screen to prevent 1 cancer death = 320
- annual low dose CT are used to screen smokers w 30y pack-year history in the age of 55-80
Colorectal cancer prevalence
2nd leading cause of death from cancer. 5% lifetime risk of developing colorectal cancer. 90% of cases happen >50 y
What are used to screen for colorectal cancer?
FOBT, sigmoidoscopy, colonoscopy, CT, colonoscopy. Screening should be in men and women aged 50-75y
Breast cancer prevalence
Is the most frequent cancer in women. Overall lifetime risk is 12%. 10y risk at age 40 is 1,5%, at age 50 it is 2,4% and at 60 it is 3,5%.
W BRCA1/2 relative risk is 10-32 (?)
What are the screening methods in breast cancer?
- Self-examination: no effect on cancer mortality
- Mammography have sens 70% and spec og 90%. 23% have false positive result, require biopsy. Rate of overdo is up to 32%, small risk of radiation induced breast cancer.
- Recommendation is mammography 40(50) - 74y
What is the Wilson and Junger criteria for screening?
1) Knowledge of disease 2) knowledge of test 3) tx of disease 4) cost consideration
What is included in criteria 1 og W&J
The disease
- important health problem
- recognizable latent period w disease marker, or early symptomatic stage
- natural course of condition should be adequately understood
What is included in criteria 2 of W&J
The test
- should be simple, safe, precise and validated
- distribution of test values in the target population should be known, and is a suitable cut-off level defined and agreed upon
- the test should be acceptable to populations
What is included in criteria 3 of W&J
The treatment
- effective tx or intervention for pat is identified through early detection w evidence of early tx rather than late tx leading to better outcomes
- agreed evidence-based policies covering which individuals should be offered tx, and the appropriate tx to be offered
What is included in criteria 4 of W&J
Cost considerations
- All the cost effective primary prevention intervention should have been implemented as far as practicable
- Cost of case finding (including dx and tx) economically balanced in relation to possible expenditures on medical care as a whole
What is lead time bias?
- Longer perceived survival w screened, even if the course of disease is not altered
- Screening is more likely to detect slow growing tumors which may be less deadly
Selection bias
- If people w increased risk of disease are more likely to be screened (eg women w fh of breast ca), are more likely to join mammography program , then screening test will look worse than it is (negative outcomes among screened population will be higher than for a random sample)
- if test is more available for young healthy people (travel distance) then fewer people will have negative outcome and test seen better than it is
What are the advantages of formal screening?
- Protected tim
- Purpose of attendance understood
- as attendees are more motivated so more receptive to advice
- comprehensive coverage of the topic
- financial incentive
What are the disadvantage of formal screening?
- requires organization, time and commitment
- nonattendance problem
- users are often those in least need of the service
What are the recommended cancer screenings?
- Breast mammography 50-74y
- cervical: pap smear 21-65 or 30-65 w HPV test
- colorectal: screening adults aged 50-75
- lung: adults 55-80 who have a 30 pack year smoking history and currently smoke or have quit within past 15y
