2Cervical Cancer Risk Factors/Prevention Screening National Cancer Institute: Cervical Cancer Prevention and Screening
3Risk Factors/Prevention Avoidance of Human Papillomavirus InfectionCigarette SmokeReproductive BehaviorScreening Via Gynecologic Examinations and Cytologic ScreeningMuñoz N, Franceschi S, Bosetti C, et al.: Role of parity and human papillomavirus in cervical cancer: the IARC multicentric case-control study. Lancet 359 (9312): , 2002.
4Avoidance of HPV Infection Abstinence from sexual activityBarrier protection and/or spermicidal gel during sexual intercourseDecreases cancer incidence with a relative risk of 0.4Muñoz N, Franceschi S, Bosetti C, et al.: Role of parity and human papillomavirus in cervical cancer: the IARC multicentric case-control study. Lancet 359 (9312): , 2002.
5Avoidance of HPV Infection Vaccination against HPV-16/HPV-18 Reduces incident and persistent infections with efficacy of 91.6% (95% CI, 64.5–98.0) and 100% (95% CI, 45–100), respectively.The vaccine protects against infection with these types of HPV for at least five years. Studies are being done to find out if the protection lasts longer than 5 years.The vaccine does not protect women who are already infected with HPV.Muñoz N, Franceschi S, Bosetti C, et al.: Role of parity and human papillomavirus in cervical cancer: the IARC multicentric case-control study. Lancet 359 (9312): , 2002.
6HPV Vaccination Gardasil: 16, 18, 6, and 11 Cervarix: 16 and 18 Recommended for 11 and 12 year-old girls. It is also recommended for girls and women age 13 through 26 years of age who have not yet been vaccinated or completed the vaccine series.Ideally females should get the vaccine before they become sexually active, which is when they may be exposed to HPV.
7Cigarette SmokingAmong HPV-infected women, current and former smokers have approximately two to three times the incidence of high-grade cervical intraepithelial neoplasia or invasive cancer.Passive smoking is also associated with increased risk, but to a lesser extent.Hellberg D, Nilsson S, Haley NJ, et al.: Smoking and cervical intraepithelial neoplasia: nicotine and cotinine in serum and cervical mucus in smokers and nonsmokers. Am J Obstet Gynecol 158 (4): 910-3, 1988.
8Reproductive Behavior High parity4x the risk with women who have 7 or more full term pregnancies2-3x the risk for women with 1-2 full term pregnanciesAmong HPV infected women, and vs. Nulliparous women.Long-term use of oral contraceptives3x the risk with use of oral contraceptives for 5-9 years.4x the risk with use of oral contraceptives for 10 or more yearsMoreno V, Bosch FX, Muñoz N, et al.: Effect of oral contraceptives on risk of cervical cancer in women with human papillomavirus infection: the IARC multicentric case-control study. Lancet 359 (9312): , 2002
9Screening Via Gynecologic Examinations and Cytologic Screening Screening is not beneficial:in detecting invasive cancer in women younger than 25 years because of the low prevalence of invasive diseasein women older than 60 years if they have had a history of recent prior negative testsSasieni P, Castanon A, Cuzick J: Effectiveness of cervical screening with age: population based case-control study of prospectively recorded data. BMJ 339: b2968, 2009.
10Screening Screening With the Papanicolaou Test Regular Pap screening decreases cervical cancer incidence and mortality by at least 80%.Screening Women Without a Cervixnot helpful in women who do not have a cervix as a result of a hysterectomy for a benign condition.Among women without cervices, fewer than 1 per 1,000 had an abnormal Pap test.Sasieni P, Castanon A, Cuzick J: Effectiveness of cervical screening with age: population based case-control study of prospectively recorded data. BMJ 339: b2968, 2009.
11When to start screening Screening should be done at least once every 2 or 3 years starting within 3 years after a woman begins to have sexual intercourse.Sasieni P, Castanon A, Cuzick J: Effectiveness of cervical screening with age: population based case-control study of prospectively recorded data. BMJ 339: b2968, 2009.
12Screening IntervalA prospective cohort analysis of a randomized controlled trial.Among 2,561 women (mean age 66.7 years) with normal Papanicolaou (Pap) tests at baseline, 110 had an abnormal Pap test within the next 2 years.No woman was found to have cervical intraepithelial neoplasia (CIN) 2–3 or invasive cancer, and only one had CIN 1–2.Thus the positive-predictive value (PPV) of screening 1 year after a negative Pap test was 0%; after 2 years the PPV was 0.9%.Sasieni P, Castanon A, Cuzick J: Effectiveness of cervical screening with age: population based case-control study of prospectively recorded data. BMJ 339: b2968, 2009.
13Screening IntervalThe authors concluded that Pap tests should not be repeated within 2 years of a prior negative test.Sasieni P, Castanon A, Cuzick J: Effectiveness of cervical screening with age: population based case-control study of prospectively recorded data. BMJ 339: b2968, 2009.
14HPV TestingHPV testing is not recommended in adolescent women with ASCUS as the majority of such women are HPV-positive.HPV DNA testing is generally not appropriate or clinically useful following cytology results of LSIL, which is more severe than ASCUS, and the vast majority of such women (84%–96%) are carcinogenic HPV DNA-positive.Carozzi FM, Del Mistro A, Confortini M, et al.: Reproducibility of HPV DNA Testing by Hybrid Capture 2 in a Screening Setting. Am J Clin Pathol 124 (5): , 2005.
15Start screening for cervical cancer using Pap smear within 3 years of first sexual intercourse Pap tests should not be repeated within 2 years of a prior negative test.Screening patients who have no more cervix has no benefits.HPV vaccine should be offered to girls age years old, ideally before the first sexual intercourse.
17Breast CancerMost frequently diagnosed life-threatening cancer in women and the leading cause of cancer death among women.Increased public awareness and improved screening have led to earlier diagnosis at stages amenable to complete surgical resection and curative therapies.
18Risk Factors Age and gender Race and ethnicity Benign breast disease Personal history of breast cancerLifestyle and dietary factorsReproductive and hormonal factorsFamily history and genetic factorsExposure to ionizing radiationEnvironment factorsCostanza, M.E, Chen, W.Y. Epidemiology and risk factors for breast cancer, August 20,2009
19Breast Cancer Screening MammographyClinical Breast ExaminationBreast Self-ExaminationMagnetic Resonance Imaging
20Mammography Utilizes ionizing radiation to image breast tissue Mammography often reveals a lesion before it is palpable by clinical breast examination and, on average, 1-2 years before noted by breast self-examination.The examination is performed by compressing the breast firmly between a plastic plate and an x-ray cassette that contains special x-ray film.films are taken in mediolateral oblique and craniocaudal projections.Both views should include breast tissue from the nipple to the pectoral muscle.Two-view examinations decrease the recall rate compared with single-view examinations by eliminating concern about abnormalities due to superimposition of normal breast structures.National Cancer Institute, Breast Cancer Screening Modalities, updated April 29, 2010
21MammographyRecent advances in mammography include the development of digital mammography and the increased use of computer-aided diagnosis (CAD) systems.CAD systems have been developed to help the radiologist identify mammographic abnormalities.Digital mammography allows the image to be recorded and stored. Using computer technology, digital mammogram images can be magnified and the image modified to improve evaluation of specific areas in question.
22MammographyThe USPSTF estimates the benefit of mammography in women aged years to be a 30% reduction in risk of death from breast cancer.For women aged years, the risk of death is decreased by 17%. Although mammography guidelines have been in place for over 30 years, 20-30% of women still do not undergo screening as indicated. The two most significant factors for a woman to undergo mammography are physician recommendation and access to health insurance.Non-white women and those of lower socioeconomic status remain less likely to obtain mammography services and more likely to present with life-threatening, advanced-stage disease.
23Overall sensitivity is approximately 79% but is lower in younger women and in those with dense breast tissue. Overall specificity is approximately 90% and is lower in younger women and in those with dense breasts
24Mammographymammography remains the most cost-effective approach for breast cancer screening, the sensitivity (67.8%) and specificity (75%).mammography combined with clinical breast examination slightly improves sensitivity (77.4%) with a modest reduction in specificity (72%).
25Age to initiate screening with mammography The American Cancer Society, American College of Radiology , American Medical Association, the National Cancer Institute, and American College of Obstetrics and Gynecology all recommend starting routine screening at age 40.The American College of Physicians and the Canadian Task Force on the Periodic Health Examination recommend beginning routine screening at age 50.Fletcher, Suzanne W. , Screening for Breast Cancer, September 2009
26Mammogram USPSTF ACS ACOG 40-49 years-the decision to have a mammogram every two years is an individual one.50-74 years-every two yearsACS40-49 years-every year50-74 years-every yearACOG40-49 years-every 1-2 yearsYou should make your decision after you understand the risk and benefits that apply to you. Talk to your doctor.
27Breast self-examination (BSE) and clinical breast examination (CBE) Both breast self-examination and clinical breast examination involve inexpensive and noninvasive procedures for the regular examination of breasts..(ie, monthly for breast self-examination and annually for clinical breast examination).
29Breast self-examination (BSE) In 2002, the USPSTF found that there was inadequate evidence to make a recommendation on teaching or performing BSE.The 2009 USPSTF guidelines recommend against teaching women how to perform BSE (Grade D recommendation), based on studies that found that teaching BSE did not reduce breast cancer mortality but instead resulted in additional imaging procedures and biopsies.ACS views the exam as optional for women aged 20 and olderAt present, however, the ACOG continues to recommend counseling patients that BSE has the potential to detect palpable breast cancer and can be performed.In 2002, the USPSTF judged that evidence was inadequate to make a recommendation on teaching or performing BSE. The new USPSTF recommendations are based on a systematic evidence review by Heidi D. Nelson, MD, MPH, and colleagues published in the same issue of Annals of Internal Medicine. This systematic evidence review identified two studies published since the 2002 recommendations. These studies found that teaching BSE did not reduce breast cancer mortality but resulted in additional imaging procedures and biopsies. Therefore, the USPSTF recommended against teaching BSE on the grounds that it has no benefit for women but places them at risk of harm.The American College of Obstetricians and Gynecologists recommends that Fellows continue to follow current College guidelines for breast cancer screening. Evaluation of the new USPSTF recommendations is under way. Should the College update its guidelines in the future, Fellows would be alerted and such revised guidelines would be published in Obstetrics & Gynecology.The College continues to recommend that Fellows advise mammography screening for their patients aged 40 and older and that they counsel their patients that BSE has the potential to detect palpable breast cancer and can be performed. Fellows should be aware that the new USPSTF recommendation against routine screening mammography for women aged (a grade C recommendation) has implications for insurance coverage, as some insurers will cover only preventive services rated as an "A" or a "B" by the USPSTF. Fellows should counsel their patients that insurance coverage for "routine screening" mammography may become variable and that patients should address this question with their insurers. These recommendations do not apply to high-risk women or patients with clinical findings, and they should be managed accordingly.American College of Obstetricians and Gynecologists. Response of The American College of Obstetricians and Gynecologists toNew Breast Cancer Screening Recommendations from the U.S. PreventiveServices Task Force. http://www.acog.org/from_home/Misc/uspstfResponse.cfm
30Clinical Breast Examination USPSTF has no recommendations for this examThe ACS recommends that women aged have the exam every three years, and every year for women aged 40 and older.The ACOG's guidelines are for women to have this exam every year.
31Breast self-examination (BSE) and clinical breast examination (CBE) BSE is recommended beginning at age 20 on a monthly basis.It is best to perform this exam the same time every month, preferably at the end of a period when breast are less tender.For those with irregular menstrual cycles, perform BSE the same day each month.It is recommended that women have a CBE beginning at age 20 every one to three years, and then annually at age 40.Currently, a mammogram with a CBE is the most effective way of detecting breast cancerStudies have not shown BSE alone to reduce the number of deaths from breast cancer. However, BSE allows one to know how their breast normally feels and to notice any changes.
32Magnetic Resonance Imaging There is increasing interest in using breast magnetic resonance imaging (MRI) as a screening test for breast cancer among women at elevated risk of breast cancer based on BRCA1/2 mutation carriers, a strong family history of breast cancer, or several genetic syndromes such as Li-Fraumeni or Cowden disease.Breast MRI is a more sensitive modality for breast cancer detection as compared with screening mammography, but it is also less specificDirect back-to-back comparisons of breast MRI and mammography in young high-risk women report MRI sensitivities ranging from 71% to 100% versus mammography sensitivities of 20% to 50%. The low sensitivities of mammography are consistent with previous experience in young women and those with dense breasts. Contrast-enhancing foci are normal in healthy breasts, and false-positive results are common.[75,76] These same studies show that MRI is also associated with threefold to fivefold higher recall rates, higher false-positive rates (with specificities varying from 37%–97%), and substantially worse PPVs. Thus, women who are screened with MRI have more negative surgical biopsiesNational Cancer Institute, Breast Cancer Screening Modalities, updated April 29, 2010
33MRIThe 2007 American Cancer Society (ACS) recommends offering annual MRI, in addition to mammography, to women within certain high-risk groups including :Known BRCA mutation carriersFirst degree relatives of known BRCA mutation carriersWomen with an approximate lifetime risk of breast cancer from 20 to over 25 percentThe ACS recommends against MRI screening for women with less than a 15 percent lifetime risk and states that evidence is insufficient to support recommendations for women with risks between 15 and 20 percent.
34MRIThe National Institute for Health and Clinical Excellence (NICE) guidelines recommends offering annual MRI in addition to mammography to the following high risk groups:BRCA1 and BRCA2 mutations carriers, starting at age 30TP53 mutation carriers, starting at 20Women in their 30s with a 10-year risk >= 8 percentWomen in their 40s with a 10-year risk >= 20 percentWomen in their 40s with dense breasts and a 10-year risk >= 12 percent
35Women’s HealthA report from the Institute of Medicine (IOM) found that sex has a broad impact on biologic and disease processesThe National Institutes of Health established the Office of Research on Women's Health in 1990 to develop an agenda for future research in the field.Women's health has become a distinct clinical discipline with a focus on disorders that are disproportionately represented in women.Alzheimers diseaseAutoimmune disease
36MenopauseWomen's risk for many diseases increases at menopause, which occurs at a median age of 51.4 yearsEstrogen levels fall abruptly at menopause, inducing a variety of physiologic and metabolic responses.Rates of cardiovascular disease increase and bone density begins to decrease rapidly after menopause
37OsteoporosisOsteoporosis is about five times more common in postmenopausal women than in age-matched men, and osteoporotic hip fractures are a major cause of morbidity in elderly women.Estrogen deficiency is associated with increased osteoclast activity and a decreased number of bone-forming units, leading to net bone loss.
38ScreeningSeveral noninvasive techniques are now available for estimating skeletal mass or density.dual-energy x-ray absorptiometry (DXA)single-energy x-ray absorptiometry (SXA)quantitative CTUltrasoundDXA is a highly accurate x-ray technique that has become the standard for measuring bone density
39When to Measure Bone Mass Clinical guidelines have been developed for use of bone densitometry in clinical practice.The original National Osteoporosis Foundation guidelines recommend bone mass measurements in postmenopausal women, assuming they have one or more risk factors for osteoporosis in addition to age, gender, and estrogen deficiency.The guidelines further recommend that bone mass measurement be considered in all women by age 65Harrison’s Principle of Internal Medicine 17th edition
40When to Treat Based Upon Bone Mass Results Most guidelines suggest that patients be considered for treatment when BMD is >2.5 SD below the mean value for young adults (T-score –2.5)Treatment should also be considered in postmenopausal women with risk factors, even if BMD is not in the osteoporosis range.Risk factors for fracture:ageprior fracturefamily history of hip fracturelow body weightcigarette consumptionexcessive alcoholsteroid userheumatoid arthritisHarrison’s Principle of Internal Medicine 17th edition
41Prevention Steps to prevent osteoporosis. good diet with plenty of calcium and vitamin Da regular exercise programa healthy lifestylemedicationBone Health and Osteoporosis:A Guide for Asian Women Age 50 and OlderNational Institutes of Health Osteoporosis and Related Bone Diseases ~ National Resource Center
42PreventionAdults need 1,000 mg of calcium every day, increasing to 1,200 mg for men and women age 50 and older.Many Asian diets are low in calcium. Examples of foods that contain calcium in different amounts include:• canned sardines with bones• milk, yogurt, cheese, ice cream• oysters, soybeansCalcium SupplementsBone Health and Osteoporosis:A Guide for Asian Women Age 50 and OlderNational Institutes of Health Osteoporosis and Related Bone Diseases ~ National Resource Center
43Prevention Institute of Medicine recommends daily intakes of 200 IU for adults <50 years of age400 IU for those from 50–70 years600 IU for those >70 yearsPeople can get enough vitamin D from such sources as:• 15 minutes of exposure to sunlight• egg yolks• saltwater fish• fortified dairy products• vitamin and mineral supplementsBone Health and Osteoporosis:A Guide for Asian Women Age 50 and OlderNational Institutes of Health Osteoporosis and Related Bone Diseases ~ National Resource Center
44PreventionExercisePhysical activity is also important to prevent osteoporosis and reduce falls that can result in fractures.Weight-bearing activities can help you maintain strong bonesA Healthy LifestyleSmoking and drinking too much alcohol are bad for bones. To protect your bones,do not smoke, and if you drink alcoholic beverages, do so in moderation.Bone Health and Osteoporosis:A Guide for Asian Women Age 50 and OlderNational Institutes of Health Osteoporosis and Related Bone Diseases ~ National Resource Center
45Prevention Risk Factor Reduction Patients should be thoroughly educated to reduce the impact of modifiable risk factors associated with bone loss and falling.Medications should be reviewed . Eg. GlucocorticoidFor those on thyroid hormone replacement, TSH testing should be performed to determine that an excessive dose is not being used, as thyrotoxicosis can be associated with increased bone loss.Harrison’s Principle of Internal Medicine 17th edition
46Prevention Reducing risk factors for falling : Review of the medical regimen for any drugs that might be associated with orthostatic hypotension and/or sedationPatients should be instructed about environmental safetyeliminating exposed wires, curtain strings, slippery rugs, and mobile tableschecking carpet conditionproviding good light in paths to bathrooms and outside the homeTreatment for impaired vision is recommendedElderly patients with neurologic impairment are particularly at risk of falling and require specialized supervision and care.Harrison’s Principle of Internal Medicine 17th edition
47Pharmacologic Bisphosphonate drugs: alendronate Calcitonin Raloxifene - a selective estrogen receptor modulator (SERM)Teriparatide- a form of the parathyroid hormoneEstrogen therapy