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Cancer Screening 101: What Do I Recommend To My Patients? Kenneth R. Kunz, M.D., Ph.D. Medical Oncology Pharmaceutical Sciences [email protected] The Death of Achilles; Peter Paul Rubens, 1635 Conflict of Interest I have no involvement with industry and cannot identify any conflict of interest 25 May 2017 Cancer Screening 101 2 Can We Eliminate Cancer? There is a belief that if we just managed better we could eliminate cancer In 1971 Nixon declared a “War on Cancer” Trillions of dollars have been spent on research The result is that cancer has now risen to be the number one cause of death in North America On December 23, 1971, President Richard Nixon signed the National Cancer Act and declared "war on cancer." 25 May 2017 Cancer Screening 3 The Ebers Papyrus (1550 BC) discusses the management of cancer 3,200-Year-Old Skeleton is Oldest Known Case of Human Cancer Cancer has long been considered a modern disease Current, modern risks absent in ancient populations British archaeologists in Nile River Valley 3,200-yr-old skeleton of a young man riddled with cancer Skull radiograph featuring myeloma 25 May 2017 Cancer Screening 101 4 72 million–year-old Gorgosaurus died from complications of bone cancer There will never be a future without cancer because cancer is a natural consequence of living 25-May-17 breast cancer National Geographic News. Nov. 24, 2003 5 What is Cancer? CT scan: spread to liver Appearance at autopsy The cells making up normal tissue are well organized because they have a specific function. Cancer occurs when these cells undergo mutations that transform them into bizarre looking shapes that show an invasive, infiltrative and destructive growth pattern, spreading by erosion and digestion through tissue planes into adjacent organs, along nerve sheaths, and penetrating lymphatic channels and blood vessels to cause widespread, distant metastases and death. Normal pancreas cells Pancreatic Cancer Cancer cells in blood vessels They get there on purpose 25 May 2017 Cancer Screening 101 6 Statistics Canada 2009 Cancer 30% of deaths Heart attack 21% Stroke 6% Population 34 million Statistics Canada 2014 191,300 new cases of cancer and 76,600 deaths Every hour of every day 22 Canadians diagnosed with cancer and nine people die of cancer (500 per day, 200 deaths) About 1/3rd of all deaths in Canada are due to cancer More men than women die of cancer: 52% 48% The average Canadian is at high risk for cancer Alive with Pleasure Cancer is increasing by 1.5% per year Population is growing and aging Risk increases with age and related exposures Smoking, overweight and inactivity are the chief factors Related to adverse childhood events (Vincent Felidy) Susceptibility modified risk factors such as family history 1 week groceries = $1.23by individual 1 week groceries = $341.98 25 May 2017 Cancer Screening 101 7 Big Corporations Promote Chronic Disease: by providing an over-abundance of inexpensive, good tasting, super-sized, calorie dense, preservative rich processed food, which is widely available with little or no physical effort. $= 25 May 2017 Prostate Cancer 8 Canadian Cancer Statistics 2014 Type New Cases Deaths Mortality Rate Lung 26,100 20,500 79% Breast 24,600 5,100 21% Colorectal 24,400 9,300 38% Prostate 23,600 4,000 17% Bladder 8,000 2,200 28% Lymphoma 8,000 2,600 33% Cervix (20th) 1,450 380 26% 25 May 2017 Cancer Screening 101 9 Lung Cancer Screening in Canada Seventy Jumbo Jets NOT RECOMMENDED: for asymptomatic individuals Canadian Task Force on Preventive Health Care (2003) 1. Nconcluded Engl J Med 2013; 368:1980-1991. May 23,CT2013 “insufficient evidence to recommend scan, 2. Nradiography, Engl J Medor 2013; 369:245-254. July 18th, 2013 sputum cytology screening for lung cancer” In 2013 the US National Lung Screening Trial showed a 20% reduction in lung ca. mortality in 55-74 yrs. with 30 pack/years screened within 15 years quitting In 2014 the USPSTF recommends annual screening for lung cancer with low-dose CT for ages 55 to 80 yrs. who have a 30 pack-year smoking history and currently smoke or have quit within the past 15 years 25 May 2017 Cancer Screening 101 10 Dr. Jennifer Telford, Gastroenterologist St. Paul’s Hospital Colorectal Cancer Screening Despite excellent screening and preventative strategies colorectal cancer remains a major public health problem Early detection decreases the incidence and mortality rate with less need for surgery, colostomy and chemo/XRT Screening is cost effective In 2013 British Columbia introduced a high quality, population-based screening program Target population: asymptomatic BC residents age 50 to 74 years 25 May 2017 Cancer Screening 101 11 Average Risk Colorectal Cancer Screening Fecal immunochemical test (FIT) every two years Patient receives requisition from primary care provider Picks up FIT from lab, completes at home, returns to lab Results Mailed to GP, BCCA Normal result: BCCA recalls patient for rescreening in two years Abnormal test: patient assessed for colonoscopy Primary Care Providers play the key role 25 May 2017 Cancer Screening 101 12 Higher Than Average Risk CRC Screening: Straight to Colonoscopy Who is high risk? First degree relative diagnosed with colon cancer under the age of 60 2 or more first degree relatives with colon cancer diagnosed at any age A personal history of adenomas Note on adenomatous polyps Prevalence of polyps is 25% by age 50, and 50% by age 70 Adenomas > 1 cm have 15% chance of progression to cancer over a 10yr period Adenomas > 2 cm have a 40% likelihood of malignant transformation 25 May 2017 Cancer Screening 101 13 Colorectal Cancer Screening High Risk Screening interval: Colonoscopy every five years for patients with family history of colon cancer; Colonoscopy in five years after a patient has low risk adenoma(s) identified; Colonoscopy in three years after a patient has high risk adenoma(s) identified 25 May 2017 Cancer Screening 101 14 Colonoscopy: sequence of events for high risk patients/or positive FIT Pathway is facilitated for patients through HA coordinators working with centralized BC Cancer Agency colon screening registry BCCA facilitates referral to HA patient coordinator Patient is educated, scheduled for, and undergoes procedure Colonoscopist provides report to GP, coordinator, BCCA Pathologist reviews specimen and sends report to GP, coordinator, BCCA BCCA provides next recommended screening interval information to GP Coordinator provides results to patient by 14 days 25 May 2017 Cancer Screening 101 15 Colonoscopy Sequence of Events (con’t) Normal result/no adenomas: BCCA recalls patient for FIT in 10 years Patient with family history is recalled for colonoscopy in five years by BCCA Low risk adenoma repeat colonoscopy in 5 years High risk adenoma repeat colonoscopy in 3 years Cancer or IBD detected, patient taken out of program Colonoscopist facilitates further management with GP 25 May 2017 Cancer Screening 101 16 Fecal Immunochemical Test (FIT) Antibodies directed against human globin Approved by Health Canada in 2008, many other countries Automated test reading, quantitative results Superior to gFOBT –which is now considered obsolete Higher sensitivity for CRC (80% vs. 40%) Higher sensitivity for advanced adenomas (40% vs. 20%) More specific for colon blood Unaffected by diet or medications Improved compliance---one stool specimen required Disadvantages: more expensive, sample can degrade 25 May 2017 Cancer Screening 101 17 FIT Not Recommended for: Screening in individuals less than 50 or over 74 yrs. Individuals in poor health who cannot undergo colonoscopy Individuals up to date with CRC screening Individuals already in a colonoscopy surveillance program Individuals with GI symptoms or IBD 25 May 2017 Cancer Screening 101 18 Why a CRC Screening Program? Ad hoc or opportunistic screening has had no significant impact on incidence or mortality of CRC over last 20 yrs. Inconsistent follow-up & colonoscopy, pathology, etc. Final points: There are major risks associated with screening programs Colonoscopy is an operator dependant, invasive and costly procedure: perforation, bleeding, missed lesions There are major benefits associated with screening programs—reduced mortality Family Physicians play a key role in reducing CRC rates 25 May 2017 Cancer Screening 101 19 Breast Cancer Screening Program of BC The Natural History of Breast Cancer . There has been considerable back and forth in the literature n= 1,372 regarding the potential harms and benefits of breast cancer . screening/mammography . 100 Survival % 80 60 40 20 Seven different studies Mammography . reduces mortality: Lessons From the Mammography Wars. N Engl J Med 2010;363:1076-79 . . . Mammography not reduce mortality: 25 yr. follow-up for . . does . . breast and mortality of the Canadian National Breast 1 2 3 4 cancer 5 6 incidence 7 8 9 10 Years from alleged onset Screening Study: randomized screening trial. BMJ 2014;348:g366 (11 February 2014) What are the current recommendations in BC? Screening is strongly recommended 25 May 2017 Cancer Screening 101 20 Dr. Christine Wilson, Medical Director, BCCA Screening Mammography Program Breast Cancer Screening: Quick Facts Breast cancer is the most common type of cancer diagnosed in Canadian women BC has one of the lowest incidence rates and the second lowest mortality rate of breast cancer in the country In 2014 an est. 3,600 women will be diagnosed with breast cancer in BC, and 570 will die from the disease Over 80 % of new breast cancers diagnosed each year in BC are in women age 50 or older Mammograms find cancers in earlier stages– when there are more treatment options and better chance for cure 25 May 2017 Cancer Screening 101 21 Breast Cancer Screening: Quick Facts 281,715 screening mammograms were performed in BC in 2012, and 1,264 breast cancers were reported (4.5 per 1,000 exams) “Research has shown a 25% reduction in deaths from breast cancer among women who are screened through the Screening Mammography Program of BC” 25 May 2017 Cancer Screening 101 22 February 4, 2014: Revised Breast Cancer Screening Recommendations in BC New recommendation for women 40-74 years old with FHx of breast cancer in a first degree relative (mother, sister or daughter) to receive annual screening More than twice as likely to develop breast cancer Women ages 40 to 49 will continue to have access to screening every two years without a doctor’s referral Encouraged to make an informed choice by speaking to their health provider about benefits and limitations of screening Women ages 50 to 74 should be screened every two years This age group benefits most from routine screening. 25 May 2017 Cancer Screening 101 23 Other New Policy Recommendations Women age 75 and older continue to have access to breast screening without a doctor’s referral Encouraged to make an informed choice by speaking to their health provider about the benefits/limitations in context of their personal health Women age 40 and younger with a personal high risk of developing breast cancer will require a doctor’s referral Provided they not have breast implants or indication for diagnostic mammogram 25 May 2017 Cancer Screening 101 24 Other New Policy Recommendations Routine self-breast examinations as only screening method not recommended for women at average risk Routine clinical breast exam: Insufficient evidence to recommend in the absence of symptoms alone or in conjunction with mammography Routine breast MRI screening of women at average risk is not recommended All women should be familiar with their breast texture and appearance and bring any concerns to their doctor 25 May 2017 Cancer Screening 101 25 Limitations of Breast Cancer Screening Mammograms are not perfect Age or breast density can make cancers more or less difficult to see Mammography does not detect all cancers. Mammograms find 4 in 5 cancers – some cancers are often too small or in an area that is difficult to view Mammograms may lead to additional testing On average, 8% of women screened will require additional testing. Of the women recalled only 0.4% will result in a cancer diagnosis 25 May 2017 Cancer Screening 101 26 Screening for Prostate Cancer NOT RECOMMENDED Many men are harmed as a result of prostate cancer screening and few, if any, benefit Do not screen for prostate cancer by either PSA or rectal examination Even in asymptomatic high risk individuals Screening finds cancer, but there is currently inadequate evidence that doing so extends life, while it exposes men to high risk of danger and side effects 25 May 2017 Cancer Screening 101 27 Marette Lee ‐ Gynecologic Oncology, November 2, 2013 Cervical Cancer Screening Update Normal pap test Approximately 200 new cases per year in BC 20% of women have had inadequate screening Poorly screened women, more advanced disease, high MR 10% of eligible women have NEVER had a Pap smear Some populations are screened less well and have higher incidences of cervical cancer Cervical cancer is 4‐6 times higher in First Nations women 25 May 2017 Cancer Screening 101 28 Current Screening Recommendations Screening initiation Age 21 or 3 years after sexual activity Negative or benign Q12 months x 3 negative, then Q24mo Over 69 Stop if 3 normal in last decade Pregnant Screen in early pregnancy HIV positive, immunosuppression Q6 months x 2, then yearly Previous CIN 2/3 Annually Post hysterectomy (total) Stop if prior normal and benign Continue yearly X 3 if history of dysplasia 25 May 2017 Cancer Screening 101 29 How Can Providers Fight Cervical Cancer ? Identify eligible women for screening Obtain high quality smears Make appropriate referrals for abnormal results Encourage smoking cessation Encourage and provide HPV vaccination – up to 45y YES!! Offer to women who have had abnormal Paps, dysplasia Bivalent vaccine available for free to <26yo 25 May 2017 Cancer Screening 101 30 Cancer Screening 101 Questions? “Your cells take their signals from your beliefs” 25 May 2017 Cancer Screening 101 31 What Kind of Food do You Eat? How Much Food Do You Eat? 25 May 2017 Cancer Screening 101 32 Do You Get Enough Exercise? Arm Chair Suicide 25 May 2017 Exercise Prevents Cancer Cancer Screening 101 33 Do You Smoke Cigarettes? 25 May 2017 Cancer Screening 101 34