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بسم هللا الرحمن الرحيم INTRODUCTION Cancer deaths seven million half a million die from cancer each year in the United States (US) alone It is estimated that 50 percent of cancer is preventable INTRODUCTION risk factors (account for two-thirds of all cancers in the US –tobacco use, –excess weight, –poor diet, –inactivity INTRODUCTION nine modifiable risks were identified as the cause of 35 percent of cancer deaths worldwide: –smoking, –alcohol use, Harvard Report on –diet low in fruit and vegetables, Cancer Prevention Volume 2: –excess weight, Prevention of –inactivity, Human Cancer. Cancer Causes –unsafe sex, and Control –urban air pollution, 1997; 8:S1. –use of solid fuels, and –contaminated injections in health-care settings INTRODUCTION Lifestyle issues which promote cancer are also risk factors for other diseases, such as stroke, heart disease, and diabetes. TOBACCO USE –kills approximately 5 million people each year –mostly through malignancy, cardiovascular, and respiratory disease –Approximately one-half of all smokers die of a tobacco-related disease, and –adult smokers lose an average of 13 years of life due to this addiction –What Is Cancer Screening? –Evaluation of a Screening Test –Breast Cancer Screening –Cervical Cancer Screening –Colorectal Cancer Screening –Skin Cancer Screening –Prostate Cancer Screening –Lung Cancer Screening –Adherence to Cancer Screening –Future of Screening The goal of cancer screening –detect cancer at an early stage when it is treatable and curable For a screening test to be useful: –should detect cancer earlier than would occur otherwise, –should be evidence that earlier diagnosis results in improved outcomes Advances in genetics and molecular biology –will make it possible to detect cancer at earlier and earlier stages along the carcinogenesis pathway –the line between prevention and screening may narrow further, as it has for colorectal and cervical cancers The National Cancer Policy Board estimated that appropriate use of screening among –persons aged 50 and older could reduce the mortality from colorectal cancer by 30% to 80%; –women aged 50 and older could reduce mortality from breast cancer by 25% to 30%, –women aged 18 and older could reduce the rate of cervical cancer mortality by 20% to 60%. What Is Cancer Screening? lead to early detection of asymptomatic or unrecognized disease acceptable inexpensive tests or examinations in a large number of persons expeditiously to separate apparently well persons who probably have disease from those who probably do not. What Is Cancer Screening? The main objective of cancer screening is to: – reduce morbidity and mortality from a particular cancer among persons screened What Is Cancer Screening? Characteristics of Screening Tests versus Diagnostic Tests Screening Diagnosis Applied to asymptomatic groups Applied to symptomatic individuals Lower cost per test Higher cost; all necessary tests applied to identify disease Lower yield per test Higher probability of case detection Lower adverse consequences of error Failure to identify true positives can delay treatment and worsen prognosis What Is Cancer Screening? cancers suitable for screening –High morbidity and mortality, –high prevalence in a detectable preclinical state, –possibility of effective and improved treatment because of early detection, and –availability of a good screening test with high sensitivity and specificity, –low cost, and –little inconvenience and discomfort What Is Cancer Screening? cancers suitable for screening –Breast CA –Cervical CA –colorectal CA –Skin cancer Evaluation of a Screening Test If the test is abnormal, –what are the chances that disease is present? If the test result is normal, –what are the chances that disease is absent? Evaluation of a Screening Test The validity of a screening test –Sensitivity and specificity address the validity of screening tests Sensitivity is the probability of testing positive if the disease is truly present. –As sensitivity increases, false-negative decreases Specificity is the probability of screening negative if the disease is truly absent. –A highly specific test false-positive decreases Evaluation of a Screening Test The validity of a screening test –Predictive value is a function of sensitivity, specificity, and prevalence of disease PV+ is an estimate of test accuracy in predicting presence of disease; PV– is an estimate of the accuracy of the test in predicting absence of disease Definitions of Criteria for Evaluating a Screening Test Truth (Diagnostic Classification) Screening Test Results Cancer Present Cancer Absent Positive TP FP Negative FN TN Sensitivity = TP/TP + FN x 100 Specificity = TN/FP + TN x 100 PV+ = TP/TP + FP x 100 PV– = TN/TN + FN x 100 Accuracy = TP + TN/TP + TN + FP + FN x 100 FN, false-negative (number of subjects with cancer who are incorrectly classified as cancer-free by the test); FP, false-positive (number of cancer-free subjects who are incorrectly classified as having cancer by the test); PV, predictive value; TN, true-negative (number of cancer-free subjects who are correctly classified by the test); TP, true-positive (number of subjects with cancer who are correctly classified Evaluation of a Screening Test –The optimal outcome is a reduction in cancer mortality Evaluation of a Screening Test Measures of Effectiveness –Potential negative effects of screening include physical, economic, and psychological consequences of false-positives and false-negatives, the potential for overdiagnosis, the potential carcinogenic effects of screening, the labeling phenomenon. Evaluation of a Screening Test Measures of Effectiveness –Potential negative effects of screening include physical, economic, and psychological consequences of false-positives and false-negatives, the potential for overdiagnosis, the potential carcinogenic effects of screening, the labeling phenomenon. Evaluation of a Screening Test Measures of Effectiveness –Physicians should engage patients in discussions of the risks and benefits of cancer screening Table 22-5: Screening Guidelines for Breast, Colorectal, Prostate, and Cervical Cancers for Selected Health Care Organizations Ty pe of Ca nc er American Cancer Society20 U.S. Preventive Services Task Force3 National Cancer Institute's Physician Data Query (PDQ) System1 Br ea st ca nc er Annual mammography for women aged 40–69 y. No age cutoff. To the extent possible, a CBE should be performed at the time of mammography. Monthly BSE.136 Women aged 20–39 y should have a CBE from a health professional every 3 y and should perform BSE monthly.20 Recommends screening mammogram, with or without CBE, every 1–2 y. Mammography every 1–2 y for women age 40 y and older. Women at higher risk should talk with their physicians about schedule. Ce rvi cal ca nc er For all women who are, or have been, sexually active or who have reached age 21 y, Pap test and pelvic examination yearly with Pap tests or every 3 y with liquid-based tests. At or after age 30 y, women who have had 3 normal tests can be screened every 2–3 y. Women with risk factors (e.g., HPV infection) may require more frequent screening. Screening is not necessary for women who have had total hysterectomies unless the surgery was for treatment of cervical cancer. Pap test every 1–3 y for all women who are sexually active and/or have a cervix. No evidence to support an upper limit, but age 65 y can be defended in women with a history of normal and regular Pap tests. Evidence strongly suggests a decrease in mortality for regular screening with Pap tests in women who are sexually active or who have reached age 18 y. The upper limit at which such screening ceases to be effective is unknown. Col ore cta l ca nc er One of the following schedules for men and women aged 50 y and over at average risk: FOBT yearly; sigmoidoscopy every 5 y; FOBT + sigmoidoscopy every 5 y; colonoscopy every 10 y; DCBE every 5 y. Those at high risk for colorectal cancer should begin screening earlier and/or more frequently. Screening for colorectal cancer is strongly recommended for men and women aged 50 y and over. Several screening modalities are effective. Good evidence has been shown that periodic FOBT reduces mortality from colorectal cancer, and there is fair evidence that sigmoidoscopy alone or in combination with FOBT reduces mortality. No direct evidence has been shown for either colonoscopy or DCBE. FOBT either annually or biennially using rehydrated or nonrehydrated stool specimens in people aged 50 y and over decreases mortality for colorectal cancer. Regular screening by sigmoidoscopy in people over age 50 y may decrease mortality from colorectal cancer. Evidence is insufficient to determine the optimal interval for such screening. Pro sta te ca nc er PSA test and DRE should be offered annually, beginning at age 50 y, to men who have a life expectancy of at least 10 y. Men at high risk for cancer should start screening at 45 y. Men should be given the information needed to make informed decisions about prostate cancer screening. Evidence is insufficient to recommend for or against routine screening for prostate cancer using PSA testing or DRE. Evidence is insufficient to establish that a decrease in mortality occurs with screening by DRE, transrectal ultrasound, or PSA. Screening Guidelines for Breast, Colorectal, Prostate, and Cervical Cancers for Selected Health Care Organizations Type of Cancer American Cancer Society U.S. Preventive Services Task Force National Cancer Institute's Physician Data Query (PDQ) System Breast cancer Annual mammography for women aged 40–69 y. No age cutoff. To the extent possible, a CBE should be performed at the time of mammography. Monthly BSE.Women aged 20–39 y should have a CBE from a health professional every 3 y and should perform BSE monthly.20 Recommends screening mammogram, with or without CBE, every 1–2 y. Mammography every 1–2 y for women age 40 y and older. Women at higher risk should talk with their physicians about schedule. Table 22-5: Screening Guidelines for Breast, Colorectal, Prostate, and Cervical Cancers for Selected Health Care Organizations Type of Cance r American Cancer Society20 U.S. Preventive Services Task Force3 National Cancer Institute's Physician Data Query (PDQ) System1 Cervic al cancer For all women who are, or have been, sexually active or who have reached age 21 y, Pap test and pelvic examination yearly with Pap tests or every 3 y with liquid-based tests. At or after age 30 y, women who have had 3 normal tests can be screened every 2–3 y. Women with risk factors (e.g., HPV infection) may require more frequent screening. Screening is not necessary for women who have had total hysterectomies unless the surgery was for treatment of cervical cancer. Pap test every 1–3 y for all women who are sexually active and/or have a cervix. No evidence to support an upper limit, but age 65 y can be defended in women with a history of normal and regular Pap tests. Evidence strongly suggests a decrease in mortality for regular screening with Pap tests in women who are sexually active or who have reached age 18 y. The upper limit at which such screening ceases to be effective is unknown. Type of Cancer American Cancer Society20 U.S. Preventive Services Task Force3 National Cancer Institute's Physician Data Query (PDQ) System1 Colorectal cancer One of the following schedules for men and women aged 50 y and over at average risk: FOBT yearly; sigmoidoscopy every 5 y; FOBT + sigmoidoscopy every 5 y; colonoscopy every 10 y; DCBE every 5 y. Those at high risk for colorectal cancer should begin screening earlier and/or more frequently. Screening for colorectal cancer is strongly recommended for men and women aged 50 y and over. Several screening modalities are effective. Good evidence has been shown that periodic FOBT reduces mortality from colorectal cancer, and there is fair evidence that sigmoidoscopy alone or in combination with FOBT reduces mortality. No direct evidence has been shown for either colonoscopy or DCBE. FOBT either annually or biennially using rehydrated or nonrehydrated stool specimens in people aged 50 y and over decreases mortality for colorectal cancer. Regular screening by sigmoidoscopy in people over age 50 y may decrease mortality from colorectal cancer. Evidence is insufficient to determine the optimal interval for such screening. Type of Cancer American Cancer Society20 U.S. Preventive Services Task Force3 National Cancer Institute's Physician Data Query (PDQ) System1 Prostate cancer PSA test and DRE should be offered annually, beginning at age 50 y, to men who have a life expectancy of at least 10 y. Men at high risk for cancer should start screening at 45 y. Men should be given the information needed to make informed decisions about prostate cancer screening. Evidence is insufficient to recommend for or against routine screening for prostate cancer using PSA testing or DRE. Evidence is insufficient to establish that a decrease in mortality occurs with screening by DRE, transrectal ultrasound, or PSA. Breast Cancer Screening lifetime breast cancer incidence is 7.8%, Widely accepted techniques for breast cancer screening, –mammography, –clinical breast examination (CBE), and –breast self-examination (BSE). –No cancer screening test has been studied more than mammography (with or without CBE). Breast Most Cancer Screening trials have included women in their 40s, two trials began accrual at age 45. One of the Canadian trials [the first National Breast Cancer Screening Study (NBSS1)] was designed to examine mammography and CBE versus usual care for women in their 40s معاینه بالینی بدون عالمت معاینه فیزیکی نرمال در گروه با ریسک نرمال سن بین 40-20سال CBE -1هر سه سال BSE -2دوره ای سن بیش از 40سال -1ساللیانه CBE -2ماموگرافی سالیانه BSE-3دوره ای معاینه بالینی بدون عالمت معاینه فیزیکی نرمال ریسک باالی کانسر ا اشعه درمانی قبلی به قفسه صدری سن بیش از 25سال سن کمتر از 25سال -1مامو گرافی سالیانه +هر 12-6ماه BCE از 10-8سال بعد از xrtیا 40سالگی CBE -1 سالیانه BSE -2 دوره ای ریسک 5ساله سرطان پستان بیش از %1.7در خانمهای بیش از 35سال -1مامو گرافی سالیانه +هر 12-6ماه BCE BSE -2دوره ای BSE -2دوره ای -3در نظر گرفتن کاهش ریسک سابقه فامیلی شدید یا تمایل قوی ژنتیکی سن کمتر از 25 سال سن بیشتر از 25سال -1ماموگرافی سالیانه CBE+هر 12-6ماه BSE -2دوره ای MRI -3به عنوان کمک به ماموگرافی و BCE -4در نظر گرفتن کاهش ریسک -1از 25سالگی در HBOS 10-5-2سال بعد از تظاهر در جوانترین بیمار فامیل lCIS /Atypical hyperplasia -1 CBE سالیانه -2 BSE دوره ای -1ماموگرافی سالیانه CBE+هر 12-6ماه BSE -2 دوره ای -3در نظر گرفتن کاهش ریسک معاینه بالینی یافته مثبت در معاینه توده یا سفتی پوسته ریزی یا اکزما ترشح از نیپل بدون توده قابل لمس تغییرات پوست ترشح نوک پستان اریتم پوست پرتقالی ضخیم شدن /ندوالریته BSCR-5 نامشخص یا مشکوک احتماال خوش خیم BRCR-6 BSCR-7 توده سونوگرافی BI=RADS 1-3 آسپیراسیون کیست غیر ساده یا عالمت دار BSCR-7 BSCR-1 اگر جدار نامنظم و یا توده کیست باشد بیوپسی اکسیژنال توصیه می شود گزارش هر تغییری توسط بیمار کیست 4-2ماه پیگیری BSCR-5 biopsy ->BSCR-5 پیشرفت یا بزرگ شدن BSCR-1 ثبات ماموگرام کیست بدون عالمت یا ساده بیوپسی بافتی پیگیری هر 6-3ماه -/+ ماموگرافی برای 2-1 سال جهت بررسی ثبات سونوگرافی نرمال BSCR-16 BIrads=4 -5 توده یا المپ در بیش 30 سال توده :ریسک متوسط یا مشکوک بیوپسی بافتی تکه برداریی اگر CNB مقدور نباشد malignant LCIS Atypical hyper plasia ( CNBترجیحا ) خوش خیم LCISبدخیم مسیر زیر مشکوک atypical - hyperplasiaخوشخیم ولیگرافی مشکوکLCIS- Atypical hyperplas ia خوش خیم روتین و کاهش ریسک کانسر روتین خوش خیم(هم در پاتولوژی و هم در گرافی ) معاینه بالینی -/+ سونوگرافی هر 12-6 ماه برای -1 2سال تکه برداری توسط جراحی ثبات افزایش اندازه معاینه روتین ((BSCR-1 بیوپسی مجدد سونوگرافی عدم مایع FNA سونوگرافی آسپیراسیون ساده بررسی مایع )(BSCR-7 مایع(کیست) برخورد معمول ((BSCR-1 از بین رفتن نوده مانند باال از بین نرفتن توده سن کمتر از 30 یرای 2-1سیکل ماهیانه تحت نظر باشد (برای بیماران با ریسک کم بدخیمی توده یا سفتی در پستان