Download 2013 Cancer Screening full presentation

Annual Scientific Assembly
Spotlight on Cancer Screening:
Breast, Cervical, & Prostate Cancer Screening
Dr. Praveen Bansal, MD, CCFP
Regional Primary Care Lead, Central West, Cancer Care Ontario
November 23, 2013
Faculty/Presenter Disclosure
Faculty:
Dr. Praveen Bansal, MD and Regional Primary Care
Lead, Cancer Care Ontario, Mississauga
Halton/Central West Regional Cancer Program
Relationship with Commercial Interests:
Not applicable
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Disclosure of Commercial Support
Relationship with Commercial Interests:
The delivery of this Cancer Screening program is
governed by an agreement with Cancer Care Ontario.
No affiliation (financial or otherwise) with a
pharmaceutical, medical device or communications
organization
3
Mitigating Potential Bias
Not applicable
4
Outline
1) Cancer Screening Overview
2) Breast Cancer Screening Update
3) Cervical Cancer Screening Update
4) The Prostate Cancer Debate
5) Clinical Case Studies
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What is Screening?
Application of a test, examination or other
procedure to asymptomatic target population to
distinguish between:
• Those who may have the disease and
• Those who probably do not
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Types of Screening
Population-Based
Screening
Opportunistic
Case-Finding
Offered systematically to all
individuals in defined target group
within a framework of agreed
policy, protocols, quality
management, monitoring and
evaluation
Offered to an individual without
symptoms of the disease when
he/she presents to a healthcare
provider for reasons unrelated to
that disease
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Spotlight on:
Breast Cancer Screening
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Screening Recommendations
Canadian Task Force on
Preventive
Health Care (2011)
Screening
Modality
•
Mammography
•
•
•
•
MRI
•
Women 40 to 49: Recommend not routinely screening
Women 50 to 69: Recommend routinely screening
Women 70 to 74: Recommend routinely screening
Women aged 50 to 74: suggest screening every 2 to 3 years
Women aged 40 to 74 who are not at high risk for breast
cancer: Recommend not routinely screening with MRI
Women at high risk aged 30 to 69: Recommend annual
screening with MRI (in addition to mammography)
Canadian Task Force on Preventative Health: 21% reduction in mortality of
Br Ca with regular mammo screening in 50-69 year old females
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Screening Recommendations
Screening Modality
Breast self
examination (BSE)
Clinical breast
examination (CBE)
Canadian Task Force on Preventive
Health Care (2011)
Recommend not advising women to
routinely practice BSE
Recommend not routinely performing
CBE alone or in conjunction with
mammography
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Ontario Breast Screening
Program (OBSP)
• Province-wide organized breast cancer screening
program
• Ensures Ontario women at average risk aged 50 to
74 receive benefits of regular mammography
screening
• Women determined to be at high risk, aged 30 to 69
are screened annually with mammography and MRI
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OBSP Screening Intervals
Average risk: biennial recall (every 2 years)
Increased risk: annual (ongoing) recall, e.g.,
• High-risk pathology lesions
• Family history
Increased risk: one-year (temporary) recall, e.g.,
• Breast density ≥ 75%
• Radiologist, referring MD, recommendation
• Client request
High risk: annual recall
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Participation Rate (%)
Breast Cancer Screening
Participation Rate, by LHIN
100
90
80
70
60
50
40
30
20
10
0
National target: ≥ 70%
2004-2005
2006-2007
2008-2009
2010-2011
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Spotlight on:
Cervical Cancer Screening
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Cervical Cancer Natural History
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Comparison of
2005 and 2011Guidelines
Question
2005 Guidelines
2011 Guidelines
Initiation
Within 3 years of first vaginal sexual activity
with cytology (Pap test)
Age 21
Interval after
Negative Test
Annual until 3 consecutive negative cytology
tests, then every 2 to 3 years
Every 3 years
Cessation
Age 70 if adequate and negative screening
history in previous 10 years (≥ 3 negative
tests)
No change
Management guidelines for follow-up of abnormal cytology did not change
Guidelines summary: www.cancercare.on.ca/screenforlife
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Screening Initiation
• Women, age 21 and older who are or have
ever been sexually active
o Postpone screening until sexually active
o Cervical cancer rare < 25 years and extremely rare < 21
years
o 10 to 15 years to develop cervical cancer
• Aligns with other jurisdictions
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Harms of Screening Adolescents
• 90% will clear infection within 2 years
• High rates of low-grade mostly transient and
clinically inconsequential abnormalities
• Unnecessary anxiety from detection, biopsies and
treatment
• Treatment linked to possibility of adverse future
pregnancy outcomes
• No protective effect with screening
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Screening Interval
• Cytology screening every 3 years unless
immunocompromised or previously treated
for dysplasia
• No incremental benefit of screening more
frequently than every 3 years
• Aligns with other jurisdictions
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Screening Cessation
• Stop screening at age 70 if adequate and
negative screening history
o Low incidence of cancer in women who have been
adequately screened
o Potential discomfort of procedure
o Difficulties visualizing squamocolumnar junction
• Aligns with other jurisdictions
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Screening: Future State
• Currently, incidence and mortality reduced by up to
about 80% with regular Pap test screening
• Clear evidence for primary HPV screening
• Must be implemented within an organized program
• HPV test must be publicly funded
• Updated cytology guidelines to bridge transition
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Cervical Screening
Participation Rate, by LHIN
100
Ontario Cancer Plan target 2010: 85%
90
Participation Rate (%)
80
70
60
50
40
30
20
10
0
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2000-2002
2003-2005
2006-2008
2009-2011
Spotlight on:
Prostate Cancer Screening
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Prostate Cancer Screening
• No organized population-based screening
program in Ontario for prostate cancer
• Most international and national screening
guidelines recommend against population-based
prostate cancer screening
• Why?
• No conclusive evidence that screening nonsymptomatic men reduces illness or death
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Prostate Specific Antigen (PSA)
• Blood test that measures the amount of PSA in a
patient’s blood
• An elevated PSA may indicate:
• Prostate infection
• Benign prostatic hyperplasia – BPH
• Prostate cancer
• PSA test for screening is not paid for by OHIP
• PSA test for suspicion of cancer because of man’s
history and/or results of DRE, test is covered by OHIP
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Accuracy of PSA
• For every 100 men over age 50, with no symptoms, who
have the PSA test:
• 10/100 men will have higher (>3.5n g/L)than normal level
of PSA
• 3/10 men will be diagnosed with prostate cancer
• 7/10 men will not have prostate cancer
• 90/100 men will have normal (<3.5 ng/L) PSA levels
• 88/90 will not have prostate cancer
• 1-2/90 men will have prostate cancer, with normal PSA
levels
Note: Normal PSA values are age-based
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Expected Harms of Screening
• False-positive results: 100-120 of every 1000 men screened
• Most positive tests result in biopsy
• 1/3 of men that undergo biopsy = fever, infection, bleeding, urination
problems, pan
• 1% will be hospitalized
• Overdiagnosis: In most cases, prostate cancer does not grow or
cause symptoms.
• If it does grow, usually asymptomatic and does not cause any health
problems during a man’s lifetime
• Cannot distinguish indolent from aggressive cancers
• Overtreatment: treatment may not be needed for indolent cancers
• 90% of men receive treatment that are diagnosed
• Harms: ED, UI, complications from surgery
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Summary
Citation
U.S. Preventive
Services Task
Force,
(USPSTF) 2012
Summary Recommendations and Key Points
The USPSTF recommends against PSA-based screening for prostate
cancer in men in the general U.S. population, regardless of age
• Men are harmed as a result of prostate cancer screening and few, if
any, benefit
Canadian
Concluded that expansion of PSA screening practices beyond the
Partnership
current ad hoc situation is not justified and may even cause harm
Against Cancer,
2009/2012
American
College of
Physicians,
2013
• Men between ages of 50-69 should be informed about limited potential
benefits and substantial harms of screening
• Decision to screen using PSA test should be based on man’s risk for
prostate cancer, discussion of benefits and harms, general health,
personal preference
• Average-risk men<50 yoa, >69 yoa, or with life expectancy of <10-15
yrs, should not be screened
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Referral of Suspected Prostate
Cancer by Family Physicians
• Patients with signs and symptoms of prostate cancer,
including incidental PSA test results, should be referred
to Diagnostic Assessment Programs
• Diagnostic Assessment Programs
• Ontario-wide programs that provide fast tracking
diagnostic tests
• Multidisciplinary team of urologist, nurse navigator,
radiation oncologist
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Summary
• Provincial, population-based screening programs
• Breast Cancer Screening
• Average risk women ages 50-74, mammogram,
biennially
• High risk women ages 30-69, mammogram and MRI,
annually
• Cervical Cancer Screening
• Sexually active women ages 21 and older, Pap test,
triennially
• Currently, no screening guidelines for prostate cancer
for average risk men
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Clinical Case Studies
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Clinical Case Study 1
A 17-year-old old female sees you to initiate birth
control pill
She started having unprotected intercourse 2
months ago
Do you screen her for
cervical cancer?
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Clinical Case Study 2
42-year-old asymptomatic woman asks to
be screened for breast cancer
• Her grandmother was diagnosed with
breast cancer at age 65
What is your response?
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Clinical Case Study 3
A 69-year-old female had a normal Pap test
when she was 59 years old, an abnormal test
when she was 63 years old and a normal Pap
test most recently when she was 66
At what age can she safely
stop screening?
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Clinical Case Study 4
A 35-year-old woman had an ASCUS result on
her recent Pap test
What is the appropriate
next step?
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Clinical Case Study 5
39-year-old asymptomatic woman asks to be
screened for breast cancer
• Her mother was diagnosed with breast cancer
at age 37
What is your response?
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Clinical Case Study 6
Your 58-year-old average risk asymptomatic patient in a small
rural community asks about breast screening
She wonders if she should take the longer trip to Community A
where there is a new digital mammography unit; go to
Community B, which is closer and has an analogue unit; or wait
for the OBSP coach (with a digital unit) to come to town
What is your advice?
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Thank you
Dr. Praveen Bansal
[email protected]
[email protected]
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