USPSTF Cancer Screening – Flashcards

Grade D: screening not rec. if asymptomatic or does not carry high risk genetically ovarian cancer is caught late Ca125 are not specific or reliable

Screen women with a family hx. (breast,ovarian,tube, peritoneal CA) associated with BRCA mutations—positive screening results should be followed by genetic counseling then BCRA testing, if indicated. Risk stratification tools are avail. & reliable. Screen asymptomatic women 35 or less without a prior diagnosis of breast cancer who are increased risk for this dze. Risk assessment is associated with family members w/breast CA B/4 the age of 50; bilateral breast CA; breast & ovarian CA; breast CA in a male family member; multiple cases of breast CA in the family; one/+family members with 2 primary types of BCRA-related CA; Ashkenazi Jewish ethnicity (2.1%). Male breast cancer poses the highest risk. There are close to 1K BRCA mutations RF: patient age, race/ethnicity, age at menarche, age at first live childbirth, personal hx. of ductal or lobular carcinoma in situ, # of first- degree relatives with breast CA, personal hx. of breast bx., BMI, menopause status or age, breast density, estrogen & progesterone use, smoking, ETOH consumption, physical activity, and diet. Risk assessment models predictability is modest Screen as early as they can give consent- 18yrs Meds: Tamoxifen and raloxifene

Risk stratification tools are avail. to determine the need for in-depth genetic counseling, such as the Ontario Family Hx. Assessment, Manchester Scoring System, Referral Screening Tool, Pedigree Assessment Tool, and FHS-7. Tests for BRCA mutations are highly sensitive and specific for known mutations and require posttest counseling. Interventions in women who are BRCA carriers include earlier, more frequent or intensive cancer screening; risk-reducing meds such as tamoxifen or raloxifene and risk reducing surgery—mastectomy and salpingo-oophorectomy. Approximately 12% of general population will have dx of breast cancer. 1.4 % dx of ovarian cancer. (WOMEN) BRCA 1 risk for BC living till 60 is 65-75%. Ovarian live to 60s- 39% Pelvis or abdominal cancer inc chance of ovarian cancer Refer to genetic counselor for a complete genogram

True Negative- - if other memebers with cancer have been tested for BCRA genes True positive- someone else tested and you have the same. Negative- undetermined; other relatives with cancer. Don't know mutations. Higher risk for cancer. Negative BCRA 1 and 2. Positive- you have genetics. Don't know family members genetics. Mutations but don't know what they are- undetermined

Selective estrogen receptor modulators- Tamoxifen and raloxifene Tamoxifen and raloxifene reduce invasive cancer in women at risk. No evidence in BRCA mutated women. Tamoxifen 20mg daily for women Raloxifene 60mg daily for 5 years in postmenopausal women Mod net benefit of drugs for women at risk. Potential harm: thromboembolic events, endometrial cancer, and cataracts

Grade B: Screen all women aged 50-74 every 2 years Grade C: Screen women aged 40-49 every 2 years according to the patient's circumstances and values. Applies to Individuals 40-49 who do not have a known GENETIC MUTATION or HX OF CHEST RADIATION as these are significant risk factors; increasing age is the most important risk factor for most women. Lack of evidence: 75+ Refer to facilities certified under the Mammography Quality Standards Act (MQSA)

film mammography decrease breast cancer mortality in women aged 50-74 compared to younger women Harms of screening include psychological. Additional med visits, imaging, & biopsies in women w/out cancer, inconvenience d/t false-positive screening results, harms unneccessary tx & radiation exposure. Harms are moderate. False-positive results greater concern for younger women, tx of cancer that would not become clinically apparent during a woman's life (via over diagnosis) was found to be increasing problems as women age

Screening aims to identify high-grade precancerous cervical lesions to prevent the development of cervical cancer and early-stage asymptomatic invasive cervical cancer. HPV infection is associated with nearly all cases of cervical cancer; other risks include HIV infection, a compromised immune system, in utero exposure to diethylstilbestrol, and previous treatment of a high-grade precancerous lesion or cervical cancer. Women aged 21-65—screen with a Pap smear q.3yrs Women ages 30-65—screen with Pap/HPV (co-testing) q. 5yrs— Aggressive treatment of HPV-positive results in women younger than age 30 is avoided as is subsequent cervical insufficiency and the delivery of preterm babies. Do not screen women younger than 21; do not screen women older than age 65 who have adequate prior screening and are not at high risk; do not screen women after a total hysterectomy (no cervix) with no history of a high-grade precancer or a cervical cancer. Do not screen women younger than 30 with HPV testing alone or with co-testing b/c the potential harms of screening outweigh the potential benefits. Pap alone from ages 21-29 as HPV infected tend to clear virus B/4 cervical changes occur. Interventions for high-grade lesions—ablative and excisional therapies including cryotherapy, laser ablation, loop excision & cold knife conization. Early stage cervical CA can be treated with hysterectomy or chemoradiation. Do not aggressively treat women preterm babies & cervical insufficiency.

Adults aged 50-75, (90% w/Ca are older than 55) screen with high sensitivity fecal occult blood testing (FOTB), sigmoidoscopy (most occur here), or colonoscopy (double-contrast BE acceptable). Recent inc. in generation X (1961-1981) & millienials! (much younger patients due to lifestyle) Intervals for recommended screening strategies: Annual screening with high-sensitivity fecal occult blood testing, Sigmoidoscopy every 5 yrs. with high sensitivity FOTB every 3 yrs, Screening colonoscopy every 10 yrs. The likelihood that detection and early intervention will yield a mortality benefit declines after age 75 because of the average time between adenoma development and cancer diagnosis. 75-85 is clinical judgment. In adults age 75-85, do not automatically screen; practice shared decision-making and discuss with the patient information about test quality and availability. Do not screen adults older than 85. Focus on strategies that maximize the number of individuals who get screened overall; Those w/1st degree relatives w/colon cancer B/4 60; those w/familial polyposis or HNCC or those w/personal hx. of UC are at higher risk as well as those with metabolic syndrome. Screening guidelines are not applicable for: personal hx of cancer or adenomatous polyps. They follow a surveillance regimen. Individuals with a personal history of cancer or adenomatous polyps are followed by a surveillance regimen and these screening guidelines are not applicable. The USPSTF recommends against the use of ASA or NSAIDs for the primary prevention of colorectal cancer HNCC=hereditary nonpolyposis colorectal cancer; UC=ulcerative colitis Increased polyps can mean increased colonscopy

Screen all asymptomatic adults aged 55-80 who have a 30 pack-year smoking history and who currently smokes or has quit smoking within the past 15 years. Screen annually with a low-dose CT; Medicare will cover. Stop when not smoked >15yrs.; has limited life expectancy, or not willing to have lung surgery Age, total cumulative exposure to tobacco smoke, and years since quitting smoking are the most imp. risk factors for lung CA. Other risk factors include specific occupational exposures, radon exposure, family history, and hx. of pulmonary fibrosis or COPD. Non-small cell lung cancer is treated with surgical resection when possible & also with radiation and chemo.

lung and larynx mouth and pharynx bladder and kidney Esophagus and Pancreas Skin Possible association in prostate and breast cancer

pneumonia respiratory illness asthma and bronchitis serous otitis media sudden infant death syndrome

relevance, risks, rewards, roadblocks, repetition. Relevance- assess why it is important; consider the physical, emotional, and social aspects of smoking Risks- reinforce health to self and to significant others Rewards- improved health, well being, energy, as well as self image Roadblocks- discuss what is holding them back Repetition- bring it up at every visit

Ask, Advise, Assess, Assist, Arrange Ask- about status of smoking as v/s at every visit Advise- firm, clear, unequivocal voice about quitting, advise parents not to smoke around children Assess- smoking habits accurately and the willingness to quit Assist- the client to set up a quit date and give self help materials; use pharmacotherapy to help control the craving, sign a contract Arrange- for F/U visits and refer for counseling

inc life expectancy inc lung capacity return to normal taste and smell dec risk of heart disease reduction in blood pressure elimination of smoker's cough

There is evidence that PSA-based screening programs result in the detection of many cases of asymptomatic prostate cancer and that a substantial percentage of men who have asymptomatic cancer detected by PSA have a tumor that either will not progress or will progress so slowly that it would have remained asymptomatic for the man's lifetime; therefore PSA screening results in considerable overdiagnosis and subsequent treatment. The reduction in prostate cancer mortality 10-14 years after PSA-based screening is very small, even for men in the optimal age range of 55-69 years. African Americans and those with a family hx. of prostate cancer at 45 or greater are at greater risk. Usual benefit is to men aged 50-70. PSA testing more sensitive than DRE. (normal 2-4) Result of 4ng/ml+ detects 80% of cancers but lower cut-offs create more false positives and result in more biopsies; test q. 2 years—stop after age 75. Management strategies for localized prostate cancer include watchful waiting, active surveillance, surgery, and radiation therapy. There is no consensus regarding optimal treatment. Prostate grows- PSA grows Obstructive symptoms, digital rectal exam, peeing throughout the night Other methods of screening include the digital rectal exam and ultrasonography Harms of screening include pain, fever, bleeding, infection, and transient urinary difficulties associated with a biopsy, psychological harm of a false-positive test result, and overdiagnosis. Harms of treatment of prostate cancer include erectile dysfunction, urinary incontinence, bowel dysfunction, and a small risk for premature death. Because of the current inability to reliably distinguish tumors that will remain indolent from those destined to be lethal, many men are being subjected to the harms of CA that will never become symptomatic so that the benefits of PSA screening do not outweigh the harms!

There is insufficient evidence for this counseling for adults older than 24. Individuals with a fair skin type are at greatly increased risk for skin cancer. Fair skin type can be defined by eye and hair color; freckling; and historical factors such as usual reaction to sun exposure (always or usually burning or infrequently tanning). Effective counseling is accomplished within the primary care visit and focused on cancer prevention and appearance-focused messages such as stressing the aging effect of ultraviolet radiation on the skin to reach specific audiences. Skin CA Counseling Behavior change interventions are aimed at reducing ultraviolet radiation exposure. Sun-protective behaviors include the use of a broad-spectrum sunscreen with a sun protection factor of =/> 15, wearing hats and shade protecting clothing, avoiding the outdoors during midday hours (10AM to 3PM), and avoiding indoor tanning. Effective counseling interventions are generally low intensity; there are no appreciable harms from these interventions.

Risk assessment includes a family history of skin cancer, considerable history of sun exposure and sunburn. Groups at increased risk for melanoma include fair-skinned men and women over the age of 65; patients with atypical moles; patients with more than 50 moles. Assess skin lesions with malignant features that are noted during the routine PE; features associated with increased risk for malignancy include asymmetry, border irregularity, color variability, diameter >6mm, or rapidly changing lesions; biopsy suspicious lesions. RF: skin that burns easy, blonde or red hair, hx of expressive sun exposure including tanning bed use and sunburns, diseases or tx that suppress the immune system, personal hx of skin cancer or fam hx of melanoma in 1st degree relative, presence of 50 moles, atypical mole, or large moles Glasgow 7-point checklist Major criteria: new lesion, change in size of prior lesion, change in shape, change in color Minor criteria: diameter >7mm; inflammation, crusting or bleeding, sensory change. "The ugly duckling syndrome"- one lesion clearly does not look like the other lesions on a patient's skin- a red flag for malignancy; consider biopsy

New cancer cases estimated to be due to obesity - 41,000 Overweight and obesity contribute to 14-20% of all cancer related deaths Nearly 33% of all adults are obese and 15% of children are overweight Health risks associated with obesity: Cancer, HTN, Type-2 DM, hyperlipidemia, CAD, gallbladder disease, sleep apnea, breathlessness, OA, gout Health risks in order: DM II, Endometrial CA, Osteoarthritis, Breast CA, Gallbladder Dz, HTN, CHD, Colon CA Cancers in order: endometrial, esophageal, pancreatic, kidney, gallbladder, breast, colorectal. Total cancers- 25% Overweight is a BMI 25-29.9, obese is ≥30 BMI is calculated as wt(kg) ÷ ht(m) squared. Take into account very muscular people who's BMI may seem too high for someone with very little body fat. More than 2/3 of Americans are overweight or obese (69%) 36% obese 6.5 extremely obese From 1980 to 2000, the prevalence of obesity among adolescents tripled from 5% to 15.5% The percent of adults (age 20-74) were stable from 1962 to 80, but doubled from 1980 to 2000 Trends in adolescents occurred across race, ethnicity and gender; AA girls have the highest rate

Insulin resistance, hyperglycemia Dyslipidemia (triglycerides*, HDL-C) Waist circumference Hypertension Proinflammatory state (cytokines, chemokines) Vascular perturbations (PAI-1, VEGF) Altered adipokines (leptin, adiponectin) Elevated bioavailable IGF-1 Associated with many types of cancer. Leptin- inhibits hunger Adiponectin- protein hormone that modulates a number of metabolic processes, including glucose regulation and fatty acid oxide 25% of cancer deaths are linked to obesity

Improper Diet Sedentary Lifestyle Genes load the gun; environment pulls the trigger Most weight problems are NOT from hormone imbalances

Cancers asso. with obesity: colon, breast (postmenopausal), endometrium, kidney, and esophagus Other cancers possibly associated w/ obesity: gallbladder, ovaries, pancreas Cancers associated with sedentary lifestyle: colorectal, breast, endometrium, pancreas, and prostate Women who are obese at the time of a breast cancer diagnosis and women who gain wt. after a breast cancer diagnosis are at higher risk for breast cancer recurrence and death compared with women with a normal BMI. Levels of estrogens, androgens, insulin-like growth factors, and insulin all increase with increased body fat and may promote breast cancer growth

1. Estrogen- breast, endometrium, kidney 2. Weight gain- breast 3. Distribution of body fat- breast and prostate 4. Insulin and insulin growth factors- breast, endometrium, colon, prostate 5. Gastric reflux d/t obesity- esophagus Premenopausally, the ovaries are the primary source of estrogen, but in post menopausal women, fat tissue is the most important estrogen source. Too much insulin: body stores belly fat, inc sugar cravings and appetite, makes blood sticky and likely to clot, stim the growth of cancer cells (insulin growth factors), inc inflammation and free radicals (science inflammation and cancer), dementia, major cause of heart attacks, low testosterone in men, infertility, hair loss and acne in women, increase LDL, lowers HDL, raises trig Fat produces estrogen , which inc risk of cancer

1. Insulin resistance-inc in body fat- colon, breast, endometrium, pancreas, prostate 2. Dec in endogenous steroid hormone metabolism- breast, endometrium 3. Inc in estrogen- breast 4. Dec in immune system- breast 5. Inc gut transit time- colon, pancreas (effects the bowel content) 6. Inc testosterone- prostate 7. Dec in enzymes that protect against oxidative stress- prostate ACS recommends 30 min of mod. to vigorous physical activity (above usual) over 5+ days/week; 45-60 min. of intentional physical activity is preferable. Exercise B/4 and after a CA dx. lowers cancer specific mortality and may halt the growth of cancer. Children & adolescents engage is 60 min/day of mod. to vigorous physical activity 5days/week. Acute exercise may promote the formation of free radicals, but consistent exercise will induce the production of enzymes that protect against oxidative stress Physical activity in survivors of breast cancer has been shown to be associated with a lower risk of breast cancer recurrence and death. Improved quality of life.

Consume a healthy diet with an emphasis on plant sources—5 portions of non-starchy vegetables and fruits Choose foods and drinks in amounts that help achieve and maintain healthy wt. Choose whole grains in preference to processed refined grains Limit consumption of processed and red meats Drink no more than 1 alcoholic drink per day for women or 2 per day for men Avoid salt-preserved, salted, or salty foods. After breast cancer therapy, patients with a BMI greater than 30 should be offered dietitian consultation and a comprehensive supervised lifestyle intervention program that includes a reduced calorie diet of 1200-1500 calories, increased physical activity and behavioral strategies. Drinking increases risk of breast cancer reoccurrence and breast cancer death. Overwgt and postmenopausal woman had the most reoccurrence.

No single vitamin.mineral prevents cancer Some inc risk including Vitamin E- prostate, Beta-carotene (vit A)- lung CA. Vitamin & mineral supplementation does not improve physical performance when added to a healthy, well balanced diet Natural sources of vitamins/minerals from natural foods unless contraindicated

Exclusively for 6 mos and continue with complementary feeding thereafter Has been found to: 1. prevent breast cancer in mothers, 2. prevent overwgt and obesity in children, 3. protect the babies immune system

A- cervical cancer, colorectal cancer B- Breast CA, Breast Cancer Film 50-74, lung CA, Skin cancer 24; breast film 75+

Pap smear- abnormal cells- infection and inflammation. Pap smear is not a test for HPV per se, it provides indirect evidence of HPV infection because it detects epithelial cellular changes that are almost always due to HPV. HPV- looks for high risk HPV types and cervical cells.