Mammograms The USPTF is comprised of an independent panel of experts in Primary care and prevention No new trials performed, reviewed data that has been available for years.
Mammograms The USPTF states that the risk reduction afforded by Mammography in the 39-49 and 50-59 age ranges is the same ~0.85/0.86 However they state the Absolute risk in the 40’s is lower than other groups so potential harm may outweigh benefits 0.05 women could develop cancer 10-30 years from the small amount radiation exposure
Mammograms The recommendation to not screen in this age group reflects a value judgment both on the risks and benefits and acceptable cost These value judgments on risks and benefits based on a less than perfect screening modality There is no data about whether women would sacrifice years of life, for reduced anxiety of increased screening
Mammograms ACOG still recommends screening mammograms every 1-2 years in the 40-49 and annually after age 50
Mammograms HHS Secretary Kathleen Sebelius states that CMS would not be changing its mammogram coverage policy
Mammograms The USPSTF recommends against routine screening mammography in women aged 40 to 49 years. The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms. (grade C recommendation)
Mammograms The USPSTF recommends biennial screening mammography for women aged 50 to 74 years. (grade B recommendation) The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older. (grade I statement)
Mammograms The USPSTF recommends against teaching breast self-examination (BSE). (grade D recommendation) The 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 (grade I statement)
Mammograms The American College of Obstetricians and Gynecologists (ACOG) maintains its current advice that women in their 40s continue mammography screening every one to two years and women age 50 or older continue annual screening. Screening mammography every 1-2 years for women aged 40-49 years
Mammograms ACOG Screening mammography every year for women aged 50 years or older. BSE has the potential to detect palpable breast cancer and can be recommended. CBE every year for women aged 19 or older
Mammograms ACOG strongly supports shared decision making between doctor and patient, and in the case of screening for breast cancer, it is essential.
Breast Cancer Screening Recommendations Organization/NationStart Mammograms (age)Frequency (years) USPSTF502 AAFP401-2 American Cancer Society401 American College of Ob-Gyn401-2 A College of Preventive Medicine501-2 A College of Radiologists401 World Health Organization501-2
Hereditary Breast cancer Approximately 7% of breast cancer results from genetic mutations The majority (approximately 84%) of hereditary breast and ovarian cancer results from inherited mutations in two genes called BRCA1 (52%) and BRCA2 (32%). About 1 in 500 people carry a mutation in either the BRCA1 or the BRCA2 genes Generally, mutations in BRCA1 and BRCA2 are associated with a 45% to 87% risk of breast cancer by age 70
Hereditary Breast cancer The high survival rate of women diagnosed with early- stage breast cancer warrants heightened surveillance for women who carry mutations in BRCA1 and BRCA2 Screening should commence at an earlier age in recognition of the early age of onset of hereditary breast cancer The National Comprehensive Cancer Network, recommends the initiation of clinical breast examinations, mammography, and MRI at age 25
Surveillance for Hereditary Breast Cancer www.nccn.org Cancer 2004;100:479-89 NEJM 2004;351:427-37 ProcedureAge to beginFrequency Breast self-exam18 yrsMonthly Clinical breast exam 25 yrsTwice a year Mammography25 yrsYearly MRI25 yrsYearly
“Red Flags” for Hereditary Breast and Ovarian Cancer Syndrome Breast cancer before age 50 Ovarian cancer at any age Male breast cancer at any age Multiple primary cancers Ashkenazi Jewish ancestry Relatives of a BRCA mutation carrier Cancer 2005 Dec 15;104(12):2807-16 Science 2003;302:643-6 American Society of Breast Surgeons, June 12, 2006 www.nccn.org
Cervical Screening The incidence of cervical cancer has decreased more than 50% in the past 30 years because of widespread screening with cervical cytology. The American Cancer Society estimates 11,270 new cases of cervical cancer in the United States in 2009, with 4,070 deaths from the disease
Cervical Screening Cervical cancer screening should begin at age 21 years The recommendation to start screening at age 21 years regardless of the age of onset of sexual intercourse is based in part on the very low incidence of cancer in younger women. It is also based on the potential for adverse effects associated with follow-up of young women with abnormal cytology screening results.
Cervical Screening In contrast to the high rate of infection with HPV in sexually active adolescents, invasive cervical cancer is very rare in women younger than age 21 years.
Cervical Screening Cervical cytology screening is recommended every 2 years for women aged 21–29 years, with either conventional or liquid-based cytology. Women aged 30 years and older who have had three consecutive cervical cytology test results that are negative for intraepithelial lesions and malignancy may be screened every 3 years.
Cervical Screening Certain risk factors have been associated with CIN in observational studies; women with any of the following risk factors may require more frequent cervical cytology screening: –Women who are infected with human immunodeficiency virus (HIV) –Women who are immunosuppressed (such as those who have received renal transplants) –Women who were exposed to diethylstilbestrol in utero –Women previously treated for CIN 2, CIN 3, or cancer
Cervical Screening It has been demonstrated, however, that the rate of dysplasia decreases as the number of sequential negative Pap test results increases
Cervical Screening Formal cost-effective analysis of data from this national program showed that the most cost-effective strategy for cervical cancer screening is cytology testing no more often than every 3 years in women with prior normal screening test results
Cervical Screening It is important to educate patients about the nature of cervical cytology, its limitations, and the rationale for prolonging the screening interval beyond every year. In addition, regardless of the frequency of cervical cytology screening, physicians also should inform their patients that annual gynecologic examinations may still be appropriate even if cervical cytology is not performed at each visit.
Cervical Screening Because cervical cancer develops slowly and risk factors decrease with age, it is reasonable to discontinue cervical cancer screening at either 65 years of age or 70 years of age in women who have three or more negative cytology test results in a row and no abnormal test results in the past 10 years. If screening is discontinued, risk factors should be assessed during the annual examination to determine if reinitiating screening is appropriate
Cervical Screening Women who had high-grade cervical intraepithelial lesions before hysterectomy can develop recurrent intra-epithelial neoplasia or carcinoma at the vaginal cuff many years postoperatively
Cervical Screening Women who have had a hysterectomy with removal of the cervix and have a history of CIN 2 or CIN 3—or in whom a negative history cannot be documented—should continue to be screened even after their period of post treatment surveillance. Whereas the screening interval may then be extended, there are no good data to support or refute discontinuing screening in this population.
HPV More than 100 genotypes of HPV have been discovered 30 of these effect the genital tract, and 15 of these have been associated with cervical cancer 70 % of cervical cancer result from infection with HPV 16 and 18 90% of Genital wart are caused by 6 and 11
HPV Human papillomavirus causes carcinogenesis in the transformation zone of the cervix, where the process of squamous metaplasia replaces columnar with squamous epithelium
HPV Human papillomavirus infections are commonly acquired by young women shortly after the initiation of vaginal intercourse but, in most, they are cleared by the immune system within 1– 2 years without producing neoplastic changes. The risk of neoplastic transformation increases in those women whose infections persist
HPV Since infection is sexually transmitted and is usually transient, the prevalence of HPV infections is highest among sexually active women in their 20s
HPV The majority of HPV infections are self- limited and spontaneously clear within a several-year period as a result of cell- mediated immunity By 23 months, more than 80% had cleared their HPV infections
HPV Although the clinical significance of HPV perinatal transmission is unknown, this route of transmission is well documented. A recent study of oral and genital HPV infections in infants born to both HPV-positive and HPV- negative women detected HPV DNA in 6% of the infants at birth, 13% at 6 weeks after birth, and 9% between 3 to 24 months of age
HPV There are 2 Vaccinations that are currently approved by the FDA: Gardasil Cervarix
HPV Testing for HPV is currently not recommended before vaccination
HPV Gardasil was approved for use in 2006 Gardasil is a quadra valent inactivated vaccine that protects against Low Risk HPV 6 and 11 and High Risk 16 and 18. Gardasil is approved for both Females and Males form age 9-26
HPV Gardasil is a recombinant vaccine Best given prior to exposure to HPV 3 dose series –Now –2 months after first dose –6 months after first dose –No booster recommended
HPV Gardasil should not be given to those with Yeast Allergy
HPV Cervarix approved in 2009 Cervarix is a bivalent vaccine that protects against High Risk HPV 16-18 3 dose series –Now –2 months after first dose –6 months after first dose –No booster recommended
HPV Cervarix should not be given to those with Latex allergy
HPV vaccination guidelines Organization/NationStart VaccineCatch Up ACIP 11-1213-2 6 American College of Ob-Gyn9-26 American Cancer Society11-18None World Health Organization9-13
HPV Vaccination of immunosuppressed patients is not contraindicated, yet they may not mount a robust response Males can be vaccinated with Gardasil but not Cervarix at this time
Future ? Anal Pap smears –4000 cases of anal cancer in women in 2003 and in contrast to cervical cancer the rates are increasing
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