Presentation on theme: "CANCER SCREENING LATEST EVIDENCE"— Presentation transcript:
1 CANCER SCREENING LATEST EVIDENCE Madeleine Makhlouf Akel, MDAmerican University Of BeirutLebanese Society of Family Medicine5th annual conferenceNov. 11–12, 2006.
2 US Mortality, 2003 No. of deaths % of all deaths Rank Cause of Death 1. Heart Diseases 685,2. Cancer ,3. Cerebrovascular diseases 157,4. Chronic lower respiratory diseases 126,5. Accidents (Unintentional injuries) 109,6. Diabetes mellitus 74,7. Influenza and pneumonia 65,8. Alzheimer disease 63,9. Nephritis ,10. Septicemia ,Source: US Mortality Public Use Data Tape 2003, National Center for Health Statistics, Centers for Disease Control and Prevention, 2006.
3 2006 Estimated US Cancer Deaths* Men 291,270Women 273,560Lung & bronchus 31%Colon & rectum 10%Prostate 9%Pancreas 6%Leukemia 4%Liver & intrahepatic 4% bile ductEsophagus 4%Non-Hodgkin % lymphomaUrinary bladder 3%Kidney 3%All other sites %26% Lung & bronchus15% Breast10% Colon & rectum6% Pancreas6% Ovary4% Leukemia3% Non-Hodgkin lymphoma3% Uterine corpus2% Multiple myeloma2% Brain/ONS23% All other sitesONS=Other nervous system.Source: American Cancer Society, 2006.
4 Cerebrovascular Diseases Change in the US Death Rates* by Cause, & 2003Rate Per 100,00019502003Pneumonia/ InfluenzaHeart DiseasesCerebrovascular DiseasesCancer* Age-adjusted to 2000 US standard population.Sources: 1950 Mortality Data - CDC/NCHS, NVSS, Mortality Revised.2003 Mortality Data: US Mortality Public Use Data Tape, 2003, NCHS, Centers for Disease Control and Prevention, 2006
5 Early Cancer Detection Application of cancer screening in practice remains deficient despite the available recommendations
6 Early Cancer Detection One major barrier to implementation is the confusion that the physicians express regarding their knowledge of the recommendations , more importantly for the high risk patients.
7 CANCER SCREENING LATEST EVIDENCE Breast CancerColorectal CancerProstate CancerLung Cancer
9 Breast Cancer Screening Guidelines American Cancer SocietyBSE is an option starting at 20 YCBE every 3 years 20 – 40 Ymammogram every year at age 40 + CBEHigh Risk women to discuss with their Doctor:Earlier screeningMore frequent examsAdditional testing(USPSTF)BSE or CBE alone Lack evidence for recommendation for or against ( I Rec.)mammogram Every 1-2 years at age 40 +/- CBE (B Rec.)High Risk women to discuss with their Doctor:Earlier screeningMore frequent examsAdditional testing
10 At present, BSE cannot be recommended routinely. Screening for Breast Cancer with Regular BSE or CBE The Cochrane Database of Systematic Reviews 2006 Issue 4BSE:Two large population-based studies388,535 womenno statistically significant difference in breast cancer mortalityResults did not suggest a beneficial effect of screening by breast self-examinationThere is evidence for harmsAt present, BSE cannot be recommended routinely.CBE:no randomized trials of clinical breast examination
11 Reduction in breast cancer mortality of 20% Screening for Breast Cancer with Mammography The Cochrane Database of Systematic Reviews 2006 Issue 4seven trialshalf a million women.Reduction in breast cancer mortality of 20%Screening also lead to overdiagnosis and overtreatment, with estimated 30% increaseIt is thus not clear whether screening does more good than harm.
12 The highest PPVs for mammography were in: Women aged 50 years or older Studies looking at positive predictive value of screening mammography by age and family historyThe highest PPVs for mammography were in:Women aged 50 years or olderAnd women aged 40 years or older with a family history of breast cancer.Efforts to promote screening mammography should focus on women in these groups, in whom the majority of breast cancers occur and for whom mammography has the highest PPVs.JAMA Nov 24;270(20):JAMA Apr 6;271(13):982-3Ann Intern Med Dec 5;133(11):855-63.
13 What are known risk factors for breast cancer? Agefamily historyAge at first pregnancyEarly menarchyLate menopausePostmenopausal obesityUse of postmenopausal hormonesAlcohol consumptionPhysical inactivity
14 Women with High Risk for Familial Breast Cancer Specific family patterns associated with increased risk of deleterious mutations in the BRCA1 or BRCA2 gene.(both maternal and paternal family history are important)Breast Ca in:2 first degree relatives , one <50 Y at Dx.3 or more first or second degree relatives regardless of age at Dx.Breast + Ovarian Ca: in first and second degree relative.Bilateral Breast Ca: in first degree relativeBreast Ca in a male relativeOvarian Ca: in 2 or more first or second degree relatives regardless of age at Dx.
15 Women at high Risk for breast Cancer: genetic testing (USPSTF) Family history NOT associated with an increased risk for deleterious mutations in breast cancer susceptibility gene 1 (BRCA1) or gene 2 (BRCA2):(USPSTF) recommends against routine referral for genetic counseling or routine breast cancer susceptibility gene (BRCA) testing D Recommendation.fair evidence regarding important adverse ethical, legal, and social consequences that could result from routine referral and testing of these women.Interventions such as prophylactic surgery, chemoprevention, or intensive screening were shown to cause more harms in this group.
16 Women at high Risk for breast Cancer: genetic testing (USPSTF) Family history associated with an increased risk for deleterious mutations in BRCA1 or BRCA2(USPSTF) recommends to be referred for genetic counseling and evaluation for BRCA testing B Recommendation.Insufficient evidence regarding important adverse ethical, legal, and social consequences that could result from referral and testing of high-risk women.Bilateral prophylactic mastectomy BPM is associated with known harms.The USPSTF estimated that the magnitude of these potential harms is small.The USPSTF concluded that the benefits of referring women with an increased-risk family history to suitably trained health care providers outweigh the harms.
17 All observational studies methodological limitations Women at high Risk for breast Cancer: Bilateral Prophylactic mastectomy The Cochrane Database of Systematic Reviews 2006 Issue 4All observational studiesmethodological limitationsno randomized trials were found9 studies assessed psychosocial measuresResults: BPM was effective in reducing both the incidence of, and death from, breast cancerWomen should be aware of their true risk of developing breast cancer and the limitations of current evidence when considering prophylactic mastectomy
20 Colorectal Cancer Screening Guidelines American Cancer SocietyBeginning at age 50, 1 of the 5 options :Annual fecal occult blood test (FOBT) or fecal immunochemical test (FIT)A flexible sigmoidoscopy (FSIG) every 5 yearsAnnual FOBT or FIT and flexible sigmoidoscopy every 5 years*A double-contrast barium enema every 5 yearsA colonoscopy every 10 years*Combined testing is preferred over either annual FOBT or FSIG every 5 years alone.DRE is not recommended as a stand-alone test for colorectal cancerPatients at an increased risk should begin screening earlier and/or be screened more often(USPSTF)The USPSTF strongly recommends that clinicians screen men and women 50 years of age or older for colorectal cancer A recommendation.Same options as ACS guidelinesHowever:No direct evidence that screening colonoscopy or DCBE is effective in reducing mortalityNewer screening technologies (for example, computed tomographic colography) are not found effective in improving health outcomes.Patients at an increased risk should begin screening earlier and/or be screened more often
21 Screening for colorectal cancer The Cochrane Database of Systematic Reviews 2006 Issue 4 Meta-analysis of mortality results from the randomised controlled trialsObjective: To determine whether screening for colorectal cancer reduces colorectal cancer mortality and to consider the benefits and harms of screening.Screening benefits:reduction in colorectal cancer mortalitypossible reduction in cancer incidence through detection and removal of colorectal adenomaspotentially, treatment of early colorectal cancers may involve less invasive surgery.Harmful effects:The physical complications of colonoscopydisruption to lifestylestress and discomfort of testing and investigationsand the anxiety caused by falsely positive screening tests.
22 Screening for colorectal cancer The Cochrane Database of Systematic Reviews 2006 Issue 4 ConclusionAlthough screening benefits are likely to outweigh harms, more information is needed about the harmful effects of screening, the community's responses to screening and screening costs for different health care systems
23 Colorectal Cancer The conditions indicating higher than average risk personal history of colorectal cancer or adenomatous polypspersonal history of chronic inflammatory bowel diseasestrong family history of colorectal cancer or polypscancer or polyps in a first-degree relative [parent, sibling, or child] younger than 60or in 2 first-degree relatives of any ageknown family history of hereditary colorectal cancer syndromes (familial adenomatous polyposis or hereditary nonpolyposis colon cancer)
24 Colorectal cancer Risk Category Age to Begin Recommend. Comments INCREASED RISKPeople with a single, small(< 1 cm) adenoma3-6 years afterthe initialpolypectomyColonoscopy1If the exam is normal, thepatient can thereafter bescreened as per average riskguidelines.People with a large (1 cm+) adenoma, multipleadenomas, or adenomaswith high-grade dysplasiaor villous change.Within 3 yearsafter the initialIf normal, repeat examinationin 3 years; If normal then, thePersonal history ofcurative-intent resection ofcolorectal cancerWithin 1 yearafter cancerresectionin 3 years; If normal then,repeat examination every 5years.Either colorectal cancer oradenomatous polyps, inany first-degree relativebefore age 60, or in two ormore first-degree relativesat any age (if not ahereditary syndrome).Age 40,or 10 yearsbefore theyoungest case inthe immediatefamilyEvery 5-10 years. Colorectalcancer in relatives moredistant than first-degree doesnot increase risk substantiallyabove the average riskgroup.
25 Colorectal cancer Family history of familial adenomatous polyposis Risk CategoryAge to BeginRecommend.CommentsHIGH RISKFamily history of familialadenomatous polyposis(FAP)PubertyEarlysurveillance byendoscopy, andcounseling toconsidergenetic testingIf the genetic test is positive,colectomy is indicated. Thesepatients are best referred to acenter with experience in themanagement of FAP.Family history of hereditarynon-polyposis colon cancer(HNPCC)Age 21Colonoscopyand counselingto considerIf the genetic test is positive or ifthe patient has not had genetictesting, every 1-2 years until age40, then annually. These patientsare best referred to a center withexperience in the management ofHNPCC.Inflammatory bowel diseaseChronic ulcerative colitisCrohn's diseaseCancer risk beginsto be significant 8years after theonset of pancolitis,or yearsafter the onset ofleft-sided colitiswith biopsiesfor dysplasiaEvery 1-2 years. These patientsexperience in the surveillanceand management of inflammatorybowel disease.
28 Prostate Cancer Screening Guidelines American Cancer SocietyAnd other US medical organizations:PSA and DRE(if life expectancy is at least 10 yrs)Average risk: Beginning at age 50High risk: Beginning at age 45Higher risk: Beginning at age 40(USPSTF)Evidence is insufficient to recommend for or against routine screening for prostate cancer using PSA or DRE:I recommendation
29 Prostate Cancer Conditions indicating higher than average risk Men at High risk:African Americans1or more family member (father, brother) diagnosed before age 65Men at very high risk:Multiple first-degree relatives affected at an early age
30 two randomised controlled trials 55,512 participants were included Screening for prostate cancer The Cochrane Database of Systematic Reviews 2006 Issue 4Objectives:To determine whether screening for prostate cancer reduces prostate cancer mortality and has an impact on quality of life.two randomised controlled trials55,512 participants were includedboth trials had methodological weaknesses with high risk of bias
31 Screening for prostate cancer The Cochrane Database of Systematic Reviews 2006 Issue 4 Results :Insufficient evidence to either support or refute the routine use of mass, selective or opportunistic screening compared to no screening for reducing prostate cancer mortalityno robust evidence from randomised controlled trials is available regarding the impact of screening on quality of life, harms of screening, or its economic value.Results from two ongoing large scale multicentre randomised controlled trials that will be available in the next several years are required to make evidence-based decisions regarding prostate cancer screening.
32 Prostate Cancer Screening Guidelines For men at average risk and high risk, information should be provided about what is known and what is uncertain about the benefits and limitations of early detection and treatment of prostate cancer so that they can make an informed decision about testing.
33 Prostate Cancer Screening Guidelines What if the patient asks the doctor to make the decision on his behalf?The ACS recommends that these men should be tested.Discouraging testing is not appropriate.Also not offering testing is not appropriate
34 Prostate Cancer Screening Tests Tests to Improve Specificity PSA*Advantages Disadvantages Age-adjusted PSAConsiders that BPH increases with age and accepts that detection of disease in older men is less "valuable" than in younger men Significant increase in biopsies for younger men; assumes similar PSA range for different races PSA velocity Useful for individuals with numerous PSA values over several years; may also detect cancer in patients whose PSA is < 4.0 ng/mL Requires multiple PSA values performed by the same assay technique; requires testing over prolonged intervals PSA density Directly limits the effect of BPH Inaccurate volume determinations using standard TRUS technique; expense and inconvenience of TRUSFree PSA Earlier cancer detection; eliminates PSA elevations due to BPHLimited data at present on influence of noncancerous conditions
37 Lung CancerLung cancer is the most common cause of cancer related death in the western world.It takes about 20 years to developCigarette smoking is a known cause.Most lung cancers are not found until they are advanced
38 Lung Cancer Screening Guidelines USPSTFAmerican Cancer Societyother US medical organizationsEvidence is not enough to support regular screening for lung cancer
39 Screening for lung cancer The Cochrane Database of Systematic Reviews 2006 Issue 4 Objectives:To determine whether screening for lung cancer using regular sputum examinations or chest radiography or CT chest reduces lung cancer mortality.Total of 245,610 subjects.Seven trials were included (6 randomised controlled studies and 1 non-randomised controlled trial)There were no studies with an unscreened control group.Several of the included studies had potential methodological weaknesses.There were no controlled studies of spiral CT
40 Screening for lung cancer The Cochrane Database of Systematic Reviews 2006 Issue 4 Results:frequent screening with chest x-rays was associated with an 11% relative increase in mortality from lung cancer compared with less frequent screeningA non statistically significant trend was observed for reduced mortality from lung cancer when screening with chest x-ray and sputum cytology was compared with chest x-ray aloneChest x-ray, testing sputum cytology or CT scan do not appear to have much impact on either treatment or number of deaths from lung cancer.
41 frequent chest x-ray may cause harm. More research is needed. Screening for lung cancer The Cochrane Database of Systematic Reviews 2006 Issue 4CONCLUSION:frequent chest x-ray may cause harm.More research is needed.