Oncology: Risk factors, screening and prevention

Question 1

Primary Care Responsibilities in assessing risk factors

Answer 1

● Promote healthy habits, and avoidance of identifiable risk factors
● Use primary care visits to educate patients on risk factors
● Comprehensive family history
● Identify and order recommended cancer screening
● If appropriate, order genetic screening
● Track screening results via electronic record

Question 2

Occupational Exposures

Answer 2

● Chemical
○ Asbestos – fire retardant, “fiberglass”
○ Nickel – smelting, plating
○ Cadmium – smoking, smelting, dyes
○ Benzene – petroleum

● Radiation
○ Radon – radioactive gas in the ground
○ X-ray/CT
○ Nuclear power plants

Question 3

Infectious Exposures

Answer 3

● Bacteria
○ Helicobacter pylori – Gastric
○ Chlamydia trachomatis – Cervical/ Ovarian

● Viruses
○ Human Papillomavirus (HPV) – Cervical
○ Epstein-Barr Virus (EBV) – Lymphoma
○ Human Immunodeficiency Virus (HIV) – Kaposi sarcoma, lymphoma
○ Hepatitis B – Hepatocellular carcinoma
○ Hepatitis C – Hepatocellular carcinoma

Question 4

Medical Conditions that are cancer risk factors

Answer 4

● Inflammatory bowel disease
○ Crohns, Ulcerative colitis
● Adenomatous colonic polyps
● Polycystic ovarian syndrome
● Chronic pancreatitis
● Personal history of cancer

Question 5

Biological Factors for cancer risk

Answer 5

● Age – 2/3 of all cancer cases are >65 years
● Gender: Some cancers are a concern for one gender
● Ethnicity: Certain groups are at increased risk – Ashkenazi Jew, African
decent

Question 6

Medical treatments that are cancer risks

Answer 6

● Chemotherapy
● Radiation – repeated CT exposure
● Hormone Replacement Therapy (HTR)
● Diethylstilbestrol (DES) – synthetic estrogen
○ “DES Daughters” and Sons. D/C’d in US (1971) Europe (1980s)
● Tamoxifen – Hormone therapy for breast cancer
○ Increases risk of endometrial cancer

Question 7

Cancer Predisposition Syndrome

Answer 7

○ Mutated allele from one parent (not sufficient to initiate a tumor) and a normal allele from the other parent. If the normal allele develops the mutation, tumorigenesis can be initiated
○ Increased risk of cancer, possibly multiple types, at an earlier age

Question 8

Over ____ hereditary cancers exist and are predominantly ____

Answer 8

100; autosomal dominant

Question 9

Who to Test: Personal history factors

Answer 9

● Personal Hx of breast, ovarian, pancreatic or metastatic prostate cancer (especially if under 45 years old)
● Personal Hx of colon or uterine cancer under 65 years old
● Personal Hx of 2 or more cancers

Question 10

Who to Test: Family history factors:

Answer 10

● Early breast cancers (<49 years old)
● Any ovarian, pancreatic, metastatic prostate, or male breast cancer
● Known hereditary cancer in the family
● 2 breast cancer in 1 degree relative (any age)
● 3 or more breast cancers in relatives on same side of the family

Question 11

Modifiable lifestyle risk factors for cancers

Answer 11

○ Physical Activity
○ Diet
○ BMI
○ Sun Exposure
○ Smoking

Question 12

Chemoprevention for cancer

Answer 12

○ Medications
○ Vaccines

Question 13

Modifiable Risk Factors

Answer 13

Lifestyle
Chemoprevention
Surgical Prophylaxis

Question 14

Thought to decreases risk for colon and breast cancer

Answer 14

Physical activity

Question 15

Diet cancer factors

Answer 15

■ Diets high in fat may be associated with breast, colon, prostate,
and endometrial cancers
■ Diets high in vegetables may be associated with lower risks of lung
cancer
■ Increased fiber could reduce risk of colon cancer

Question 16

For every ___kg/m2 increase over 25 kg/m2 there is a linear association with various cancers

Answer 16

5

Question 17

T/F BMI appears to have an
inverse relationship with prostate and
premenopausal breast cancer

Answer 17

T

Question 18

Sun Exposure and cancers

Answer 18

■ Basal Cell and Squamous Cell
■ Exposures in childhood and adolescence may be associated with Melanoma in adulthood

Question 19

Smoking Cessation and cancer

Answer 19

■ 30-50% reduction of 10 year mortality if they quit
■ Secondhand smoke
■ E-cigarettes
■ Smokeless or chewing tobacco

Question 20

“Natural or synthetic chemical agents to reverse, suppress, or prevent carcinogenesis before the development of invasive malignancy”

Answer 20

Chemoprevention

Question 21

Medicines & Hormone Therapy for colon cancer chemoprevention

Answer 21

○ Estrogen
○ Aspirin

Question 22

Medicines & Hormone Therapy for Breast cancer chemoprevention

Answer 22

○ Tamoxifen and Raloxifene

Question 23

Medicines & Hormone Therapy for prostate cancer chemoprevention

Answer 23

○ Finasteride and Dutasteride

Question 24

Medicines & Hormone Therapy: Immunizations

Answer 24

○ HPV
○ Hep B

Question 25

Prophylactic Surgery Specific criteria:

Answer 25

High risks individuals – remove the organ at risk
○ Significant family history
○ Genetic predisposition
● Familial polyposis, Ulcerative colitis
● Severe cervical dysplasia

Question 26

Prophylactic Surgery: BRCA-1 and BRCA-2

Answer 26

○ High risk of breast and ovarian cancer
■ BRCA-2 tied to increased risk of pancreatic cancer and melanoma
○ Prophylactic bilateral mastectomy
○ Prophylactic salpingo-oophorectomy

Question 27

_____ – Testing asymptomatic, healthy individuals with the goal
of detecting cancer early to decrease morbidity and mortality

Answer 27

Screening

Question 28

____ – increasing number, but they are typically low penetrance and provide limited predictive accuracy

Answer 28

Genetic mutations

Question 29

Screening and diagnostic tests

Answer 29

Screening Test – asymptomatic patients, attempt to find early
Diagnostic Test – performed to confirm the diagnosis

If a patient has signs and symptoms consistent with the cancer, you will
likely skip the screening test and perform the necessary diagnostic test

Question 30

the ability of a test to detect the
disease when it is present

Answer 30

Sensitivity

Question 31

the ability of a test to correctly indicate if a disease
is not present

Answer 31

Specificity

Question 32

High specificity indicates a ___ chance of false positives

Answer 32

lower

Question 33

High sensitivity indicates a lower chance of a false ____

Answer 33

negative

Question 34

____ – Proportion of people who test positive
who actually have the disease

Answer 34

Positive Predictive Value

Question 35

____ – Proportion of people who test
negative that do not have the disease

Answer 35

Negative Predictive Value

Question 36

Good Screening Tests

Answer 36

● Designed from randomized controlled trials, limiting bias
● Looks at mortality as the endpoint
○ Understanding mortality rates helps gauge if the adverse effects of
screening and treatment are worth the screening effort
● Shows reduction of advance-stage disease, or improved survival with
intervention (not strong evidence to justify mass screening)

Question 37

USPSTF Lettered recommendations

Answer 37

○ A – High certainty that the net benefit is substantial
○ B – High certainty that the net benefit is moderate to substantial
○ C – Moderate certainty that the net benefit is small (offered on a case by case basis)
○ D – High certainty that the service has no net benefit or harm out weights the benefit (recommends against the service)
○ I – Insufficient evidence to determine benefit and harm

Question 38

According to USPSTF, Self examination for breast cancer is _____

Answer 38

not recommended

Question 39

Pap smear USPSTF/ACS current guidelines

Answer 39

<21 years: Not recommended (D)
21-29 years: Cytology every 3 years (A)
30-65 years: Cytology every 5 years, w/ HPV every 3 years (A)
>65 years: Not recommended if prior normals and low risk (D)
Post total hysterectomy: Not recommended (D)

Question 40

Gold standard colonoscopy guidelines

Answer 40

45-75 years: Screen every 10 years (B), (50-75 years,

Question 41

Postmenopausal bleeding is ____ until proven otherwise

Answer 41

cancer

Question 42

Screening – Endometrial/Uterine Cancer

Answer 42

Postmenopausal bleeding is cancer until proven otherwise
● As a screening tool, transvaginal ultrasound has a high rate of
false positives, as well as limited specificity and sensitivity
● Diagnostic method is required – Endometrial biopsy
● Women with, or at risk for HNPCC, should be offered
screening annually by age 35 (eg. Endometrial biopsy)