Oncology: Risk factors, screening and prevention Flashcards
Primary Care Responsibilities in assessing risk factors
● 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
Occupational Exposures
● 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
Infectious Exposures
● 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
Medical Conditions that are cancer risk factors
● Inflammatory bowel disease
○ Crohns, Ulcerative colitis
● Adenomatous colonic polyps
● Polycystic ovarian syndrome
● Chronic pancreatitis
● Personal history of cancer
Biological Factors for cancer risk
● 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
Medical treatments that are cancer risks
● 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
Cancer Predisposition Syndrome
○ 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
Over ____ hereditary cancers exist and are predominantly ____
100; autosomal dominant
Who to Test: Personal history factors
● 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
Who to Test: Family history factors:
● 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
Modifiable lifestyle risk factors for cancers
○ Physical Activity
○ Diet
○ BMI
○ Sun Exposure
○ Smoking
Chemoprevention for cancer
○ Medications
○ Vaccines
Modifiable Risk Factors
Lifestyle
Chemoprevention
Surgical Prophylaxis
Thought to decreases risk for colon and breast cancer
Physical activity
Diet cancer factors
■ 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
For every ___kg/m2 increase over 25 kg/m2 there is a linear association with various cancers
5
T/F BMI appears to have an
inverse relationship with prostate and
premenopausal breast cancer
T
Sun Exposure and cancers
■ Basal Cell and Squamous Cell
■ Exposures in childhood and adolescence may be associated with Melanoma in adulthood
Smoking Cessation and cancer
■ 30-50% reduction of 10 year mortality if they quit
■ Secondhand smoke
■ E-cigarettes
■ Smokeless or chewing tobacco
“Natural or synthetic chemical agents to reverse, suppress, or prevent carcinogenesis before the development of invasive malignancy”
Chemoprevention
Medicines & Hormone Therapy for colon cancer chemoprevention
○ Estrogen
○ Aspirin
Medicines & Hormone Therapy for Breast cancer chemoprevention
○ Tamoxifen and Raloxifene
Medicines & Hormone Therapy for prostate cancer chemoprevention
○ Finasteride and Dutasteride
Medicines & Hormone Therapy: Immunizations
○ HPV
○ Hep B
Prophylactic Surgery Specific criteria:
High risks individuals – remove the organ at risk
○ Significant family history
○ Genetic predisposition
● Familial polyposis, Ulcerative colitis
● Severe cervical dysplasia
Prophylactic Surgery: BRCA-1 and BRCA-2
○ High risk of breast and ovarian cancer
■ BRCA-2 tied to increased risk of pancreatic cancer and melanoma
○ Prophylactic bilateral mastectomy
○ Prophylactic salpingo-oophorectomy
_____ – Testing asymptomatic, healthy individuals with the goal
of detecting cancer early to decrease morbidity and mortality
Screening
____ – increasing number, but they are typically low penetrance and provide limited predictive accuracy
Genetic mutations
Screening and diagnostic tests
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
the ability of a test to detect the
disease when it is present
Sensitivity
the ability of a test to correctly indicate if a disease
is not present
Specificity
High specificity indicates a ___ chance of false positives
lower
High sensitivity indicates a lower chance of a false ____
negative
____ – Proportion of people who test positive
who actually have the disease
Positive Predictive Value
____ – Proportion of people who test
negative that do not have the disease
Negative Predictive Value
Good Screening Tests
● 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)
USPSTF Lettered recommendations
○ 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
According to USPSTF, Self examination for breast cancer is _____
not recommended
Pap smear USPSTF/ACS current guidelines
<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)
Gold standard colonoscopy guidelines
45-75 years: Screen every 10 years (B), (50-75 years,
Postmenopausal bleeding is ____ until proven otherwise
cancer
Screening – Endometrial/Uterine Cancer
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)
