Cancer Screenings and Early Diagnostics
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1 Cancer Screenings and Early Diagnostics Ankur R. Parikh, D.O. Medical Director, Center for Advanced Individual Medicine Hematologist/Medical Oncologist Atlantic Regional Osteopathic Convention April 6 th, 2017
2 Disclosures None 2011 Rising Tide 2
3 Objectives Review epidemiology of common cancers Discuss updates in screening 2011 Rising Tide 3
4 Screening Practices Breast Lung Colorectal Prostate 2011 Rising Tide 4
5 Breast Cancer Overview Leading Sites of New Cancer Cases & Deaths: 2016 Es<mates ACS. Cancer Facts & Figures Breastcancer.org US Breast Cancer Statistics Rising Tide 5
6 Epidemiology SEER Database 2016
7 Epidemiology SEER Database 2016
8 Epidemiology SEER Database 2016
9 Epidemiology SEER Database 2016
10 Epidemiology SEER Database 2016
11 USPSTF Final Recommendation Statement - January 12, 2016 American College of Physicians: AAFP: Rising Tide 11
12 USPSTF Screening Recommendations Average risk AGE years: Individual choice AGE years: Biennial mammography screening AGE 75+: Insufficient evidence High risk women may benefit more by beginning screening in their 40s USPSTF Final Recommendation Statement Breast Cancer: Screening Document/RecommendationStatementFinal/breastcancer-screening Rising Tide 12
13 USPSTF Insufficient Evidence Due to this lack of evidence, unable to make a recommendation for or against these services: 1. Benefits and harms of screening women age Adjunctive screening in women with dense breasts 3. Effectiveness of 3-D mammography as a primary screening method for breast cancer. USPSTF Final Recommendation Statement Breast Cancer: Screening Document/RecommendationStatementFinal/breastcancer-screening Rising Tide 13
14 USPSTF Breast Self-Examination? Clinical Breast Examination? USPSTF recommends against breast self-examination Does not reduce breast cancer mortality May increase false-positive rates Alternative: breast self-awareness USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of clinical breast examination (CBE) beyond screening mammography in women 40 years or older MARIA TRIA TIRONA, MD, Edwards Comprehensive Cancer Center, Huntington, West Virginia, Am Fam Physician Feb 15;87(4): Rising Tide 14
15 American Cancer Society Screening Recommendations Average Risk AGE 40-44: Individual choice AGE 45: Annual mammography screening AGE 55+: Biennial mammography screening Clinical breast exam/self-exam: breast self-awareness High Risk AGE 30: Mammogram AND an MRI every year ACS. Breast cancer prevention and early detection. moreinformation/breastcancerearlydetection/breastcancer-early-detection-acs-recs 2011 Rising Tide 15
16 Breast Cancer Risk Assessment Tool h"ps:// Rising Tide 16
17 Identifying High Risk Patients Family History: BRCA1 or BRCA2 genes First degree relative, or the patient having the mutation BRCA1, 55-65% chance of developing breast cancer by age 70 BRCA2, 45% chance of developing breast cancer by age 70 African-American women Ashkenazi Jewish women Patients who have had radiation therapy to the chest between the ages of 10 and 30 years Patients who have a high lifetime risk of breast cancer ( 20-25%) as assessed by various breast cancer risk assessment tool ACS. Breast cancer prevention and early detection. moreinformation/breastcancerearlydetection/breastcancer-early-detection-acs-recs 2011 Rising Tide 17
18 Summary Navigating differing guidelines USPSTF vs. American Cancer Society Cost-benefit ratio Referral Refer to radiologist for mammogram If further testing needed, refer to surgeon or cancer center for biopsy IMPORTANT: Patient follow-up 2011 Rising Tide 18
19 Screening Practices Breast Lung Colorectal Prostate 2011 Rising Tide 19
20 Lung Cancer Overview Leading Sites of New Cancer Cases and Deaths: 2016 Es<mates 1. American Lung Association. Lung cancer fact sheet SEER Stat Fact Sheets: Lung and Bronchus Cancer Rising Tide 20
21 Lung Cancer Overview Leading Sites of New Cancer Cases and Deaths: 2016 Es<mates Estimated New Cases Estimated Deaths Males Females Males Females 117,920 (14%) 106,470 (13%) 85,920 (27%) 72,160 (26%) 1. American Lung Association. Lung cancer fact sheet SEER Stat Fact Sheets: Lung and Bronchus Cancer Rising Tide 21
22 Epidemiology Lung Cancer Estimated deaths compared with colon, breast, prostate, and pancreatic cancer combined Clin Chest Med December;32(4)
23 Epidemiology Lung Cancer Stage distribution and 5-year relative survival by stage at time of diagnosis for 2001 to Clin Chest Med December;32(4)
24 Epidemiology 90% of all lung cancers are related to cigarette smoking 40 pack per year smoker has 20x risk of developing lung cancer compared to non-smoker
25 5-year Survival Rates by Stage
26 Lung Cancer Screening Clinical outcome for non-small cell lung cancer is directly related to stage at diagnosis Early detection may increase the overall cure rate and allow more limited surgical resection to achieve cure Chest. 1997;111(6):1710
27 Lung Cancer Screening National Lung Screening Trial (NLST) 20% fewer lung cancer deaths among 53,000 par<cipants screened with low- dose helical (spiral) CT compared to those screened with chest X- rays. The trial ended early due to promising results 2011 Rising Tide 27
28 2011 Rising Tide 28
29 2011 Rising Tide 29
30 Lung Cancer Screening Recommendation Consensus Organization Recommendation Year US Preventative Services Task Force Annual LDCT for high-risk individuals American Cancer Society Annual LDCT for high-risk individuals American College of Chest Physicians / American Society of Clinical Oncology Annual LDCT for high-risk individuals American Association of Thoracic Surgery Annual LDCT for high-risk individuals National Comprehensive Cancer Network Annual LDCT for high-risk individuals USPSTF. Lung cancer: screening. Page/Document/UpdateSummaryFinal/lungcancer-screening 2011 Rising Tide 30
31 Identifying High Risk Patients Age 55+ Tobacco: 30 pack-year smoking history Current smoker or quit within the last 15 years Other risk factors: Genetics: Family History Exposure to radon Exposure to asbestos & other hazardous chemicals Particle pollution USPSTF. Lung cancer: screening. Page/Document/UpdateSummaryFinal/lungcancer-screening 2011 Rising Tide 31
32 Counseling for Screening Screening should only be performed when the clinician and patient are committed to pursuing follow-up investigations Providers need to be experienced with principles of screening and management of small lung nodules
33 Counseling Patients about Lung Cancer Screening Benefit Reduce risk of dying from lung cancer in high-risk patients Limitations Will not detect all lung cancers Not all patients detected to have lung cancer will avoid death from lung cancer American Cancer Society
34 Counseling Patients about Lung Cancer Screening Potential Harms High likelihood of a false positive result May need serial imaging to monitor May require invasive procedures Cost Risk for complications Not always covered by insurance Smoking cessation Not an alternative to smoking cessation American Cancer Society
35 Summary Discuss smoking cessation every visit Identify high-risk patients Age pack-year smoking history Current smoker or quit within the last 15 years Refer high-risk patients to a Multidisciplinary Lung Cancer Screening Program Board- cer<fied radiologist Have or partner with a health center that has: Board- cer<fied pulmonologists Board- cer<fied thoracic surgeons Follows a proven protocol Accredited to do CT scans by a cer<fying organiza<on Has modern mul<- slice CT equipment that does high- quality, low- dose and non- contrast spiral CT Have or partner with a health center that has: Experience and excellence in biopsy methods 2011 Rising Tide 35
36 Screening Practices Breast Lung Colorectal Prostate 2011 Rising Tide 36
37 Colorectal Cancer Overview Colon Cancer Alliance. Statistics SEER Stat Fact Sheets: Colon and rectum cancer Rising Tide 37
38 Epidemiology SEER Database 2016
39 Epidemiology SEER Database 2016
40 Epidemiology SEER Database 2016
41 Epidemiology SEER Database 2016
42 Risks for Colorectal Cancer Increased risk Family history Age Lack of physical activity Decreased risk Multivitamins containing folic acid Aspirin and other NSAIDs Postmenopausal hormone use Consumption of red meat Obesity Cigarette smoking Calcium supplementation Selenium Fruits, vegetables and fiber Alcohol use Harvard Report on Cancer Prevention, Cancer Causes and Control 1999;10:167
43 UpToDate 2016
44 Colorectal Cancer Screening Guidelines Average Risk (USPSTF) AGE 50-75: Regular screening AGE 76-84: Recommends against screening, moderate certainty that the net benefits of screening are small AGE 85+: Recommends against screening, moderate certainty that the benefits of screening do not outweigh the harms Asymptomatic African American men and women are recommended to start screening earlier ACS/US Multi-Society/ACR: 40 years ACG: 45 years USPSTF. Colorectal Cancer: Screening Rising Tide 44
45 Colorectal Cancer Screening Guidelines PREFERRED: Colonoscopy every 10 years Other tests : USPSTF APPROVED: Annual high-sensitivity fecal occult blood testing USPSTF APPROVED: Sigmoidoscopy every 5 years combined with highsensitivity fecal occult blood testing every 3 years Double-contrast barium enema every 5 years Computed tomographic (CT) colonography every 5 years Annual guaiac-based fecal occult blood test with high sensitivity for cancer Annual fecal immunochemical test (FIT) with high test sensitivity for cancer Stool DNA test with high sensitivity for cancer, interval uncertain American Cancer Society recommendations for colorectal cancer early detection Rising Tide 45
46 ACG Screening Guidelines for Colorectal Cancer Preferred CRC screening recommendations Cancer prevention tests should be offered first. The preferred CRC prevention test is colonoscopy every 10 years, beginning at age 50 (Grade 1 B) Screening should begin at age 45 years in African Americans (Grade 2 C) Cancer detection test. This test should be offered to patients who decline colonoscopy or another cancer prevention test. The preferred cancer detection test is annual FIT for blood (Grade 1 B) Alternative CRC prevention tests Flexible sigmoidoscopy every 5-10 years (Grade 2 B) CT colonography every 5 years (Grade 1 C) Alternative cancer detection tests Annual Hemoccult Sensa (Grade 1 B) Fecal DNA testing every 3 years (Grade 2 B) Rex DK, Johnson DA, Anderson JC, et al. American College of Gastroenterology Am J Gastroenterol. 2009;104: Rising Tide 46
47 Updates in ACG Screening Guidelines for Colorectal Cancer 1. Screening tests are divided into cancer prevention and cancer detection tests. Cancer prevention tests are preferred over detection tests. 2. Screening is recommended in African Americans beginning at age 45 years. 3. CT colonography every 5 years replaces double contrast barium enema as the radiographic screening alternative, when patients decline colonoscopy. 4. FIT replaces older guaiac-based fecal occult blood testing. FIT is the preferred cancer detection test. 5. Annual Hemoccult Sensa and fecal DNA testing every 3 years are alternative cancer detection tests. 6. A family history of only small tubular adenomas in first-degree relatives is not considered to increase the risk of CRC. 7. Individuals with a single first-degree relative with CRC or advanced adenomas diagnosed at age 60 years can be screened like average-risk persons. CT, computed tomography; FIT, fecal immunochemical test Rex DK, Johnson DA, Anderson JC, et al. American College of Gastroenterology Am J Gastroenterol. 2009;104: Rising Tide 47
48 Identifying High Risk Patients Personal history of: Colorectal cancer or adenomatous polyps Inflammatory bowel disease (ulcerative colitis or Crohn s disease) Family history of: Colorectal cancer or adenomatous polyps Hereditary colorectal cancer syndrome (i.e. FAP or Lynch syndrome) ACS. CRC Risk Factors cancer/colonandrectumcancer/detailedguide/ colorectal-cancer-risk-factors 2011 Rising Tide 48
49 ACG Screening Guidelines for High Risk Patients Recommendations for screening when family history is positive but evaluation for HNPCC considered not indicated: Single first-degree relative with CRC or advanced adenoma diagnosed at age >=60 years Recommended screening: same as average risk (Grade 2 B) Single first-degree with CRC or advanced adenoma diagnosed at age <60 years or two first-degree relatives with CRC or advanced adenomas. Recommended screening: colonoscopy every 5 years beginning at age 40 years or 10 years younger than age at diagnosis of the youngest affected relative (Grade 2 B) Rex DK, Johnson DA, Anderson JC, et al. American College of Gastroenterology Am J Gastroenterol. 2009;104: Rising Tide 49
50 Summary Consensus around screening average risk patients Age 50+ Colonoscopy preferred test Frequency: every 10 years Start screening earlier and more frequently for high-risk patients Refer to Gastroenterologist 2011 Rising Tide 50
51 Screening Practices Breast Lung Colorectal Prostate 2011 Rising Tide 51
52 Leading Sites of New Cancer Cases and Deaths: 2016 Estimates ACS. Cancer Facts & Figures hvp://bit.ly/1shgj3r 2011 Rising Tide 52
53 Cancer Death Rates - Males
54 Epidemiology SEER Database 2016
55 Lifetime Risk American male Lifetime risk of developing prostate cancer is 16% Risk of dying from prostate cancer is 2.9% Detected in 30% of men by age 55 Detected in 60% of men by age 80 Int J Cancer Oct;137(7):
56 Natural History These data suggest prostate cancer often grows so slowly that most men die of other causes before the disease becomes clinically advanced
57 Epidemiology SEER database accessed July 2016
58 Epidemiology SEER Database 2016
59 Epidemiology SEER Database 2016
60 Epidemiology *PSA was used for screening in early 1990s SEER Database 2016
61 N Engl J Med 2016; 375:
62 Methods Recruited men ages 50 to 69 years of age in U.K. 82,429 men from 1999 to 2009 had a PSA test 2,664 diagnosed with localized prostate cancer 1,643 underwent randomization Active monitoring (545) Radical prostatectomy (553) Radiotherapy (545) N Engl J Med 2016; 375:
63 Patient Characteristics Median age was 62 Median PSA was 4.6 ng/ml 77% had Gleason 6 tumors 76% had stage T1c disease N Engl J Med 2016; 375:
64 N Engl J Med 2016; 375:
65 Results Active monitoring were more likely to have metastatic disease N Engl J Med 2016; 375:
66 Results N Engl J Med 2016; 375:
67 Deaths 8 of 545 men assigned to active monitoring 5 of 553 men assigned to surgery 4 of 545 men assigned to radiotherapy N Engl J Med 2016; 375:
68 Comments PSA monitoring, compared to treatment of early prostate cancer, leads to increased metastasis No significant difference in death due to prostate cancer with surgery vs. radiation for low-risk or intermediate-risk patients N Engl J Med 2016; 375:
69 Identifying High Risk Patients African American Family history Patients with one or more first-degree relative diagnosed with prostate cancer earlier than age 65 Inherited gene mutations BRCA1 and BRCA2 Lynch Syndrome 2011 Rising Tide 69
70 PSA or no PSA? May 2012: USPSTF recommends AGAINST prostate-specific antigen (PSA)-based screening for prostate cancer As of December 2016, USPSTF update in progress More information: Document/UpdateSummaryDraft/prostate-cancerscreening1 USPSTF Rising Tide 70
71 Summary Most urologists have not stopped utilizing the PSA AGE 40: Set baseline, then test every few years AGE 50: Annual PSA testing Focus on the trajectory more than the single PSA values 2011 Rising Tide 71
72 Summary Some cancers can be prevented It is important to identify high risk populations Early detection can lead to improved patient outcomes! 2011 Rising Tide 72
73 Questions? 2011 Rising Tide 73
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