Definition of Cancer Screening The presumptive identification of unrecognized cancer by the application of tests, examinations, or other procedures which can be applied rapidly to an asymptomatic population to sort out those who probably have cancer from those who probably do not.

Analytic Framework for Screening (Adapted from USPSTF, Am J Prev Med 20(3S):25, 2001) 1 5 Screening Test Treatment Association Early Detection of Targeted Condition Reduced Morbidity and/or Mortality Persons At Risk Intermediate Outcome 3 4 6 2 7 8 Adverse Effects of Screening Adverse Effects of Treatment

Zapka, J. et al. J Natl Cancer Inst Monogr 2010 2010:58-71.

Screening Tests for Asymptomatic Patients Breast Cancer Screening Tests for Asymptomatic Patients (Females) Test or Procedure ACS++ USPSTF+ Mammography preceded by CBE 40+ q yr 50-74 q 2 yr with or without CBE** MRI NR IE*** Clinical breast exam (CBE) 20-39 q3 yr* IE*** 40+ q yr* Breast self exam Optional Against + USPSTF at www.ahrq.gov/clinic/uspstf/uspsbrca.htm ++ Smith RA et al. CA Cancer J Clin 60:99-119, 2010 NR = not recommended * As part of a health examination ** Before age 50, make an informed decision with your doctor *** Insufficient evidence

Average Annual In Situ Female Breast Cancer Rates, Iowa, 1973-2006 (rates expressed per 100,000 persons using 2000 U.S. population as standard) 6-fold increase

Female Breast Cancer Mortality Rates, Iowa, 1973-2006 (Rates are per 100,000 women and age-adjusted to the U.S. 2000 population.) Study (NEJM Oct 27, 2005) reported 46% of breast cancer mortality reduction attributed to screening; remainder due primarily to Improved treatment. 32% decline between 1992 and 2006

Asymptomatic Patients Prostate Cancer (Smith RA et al. CA Cancer J Clin 60:99-119; 2010 & www.ahrq.gov/clinic/uspstf/uspsprca.htm) Screening Tests for Asymptomatic Patients (Males) Test or Procedure ACS USPSTF Prostate specific antigen (PSA) test Age 50+ q yr Insufficient and digital rectal exam (DRE) thereafter* evidence for men < 75; against for men 75+ years * Require informed decision with health care provider for men who have a life expectancy of at least 10 years.

PSA Acceptance: Controversy: Widely used as cancer marker for initial diagnosis and monitoring response to therapy Aids in prediction of prostate cancer risk and of treatment outcome Controversy: Leads to diagnosis and treatment of prostate cancers that pose no real threat Disagreement over the threshold level of PSA that should indicate biopsy Levels differ by racial, ethnic, age groups Clinical trials not showing benefit

Malignant Prostate Cancer Rates, Iowa, 1973-2006 (Rates are per 100,000 men and age-adjusted to the U.S. 2000 population.) 15% decrease in incidence between 1994 and 2006 37% decrease in mortality between 1994 and 2006

Avenues for Cancer Prevention and Control Primary Secondary Tertiary Prevention Screening Early Detection Treatment Rehabilitation Palliative Care Quality of Life/Care Genes Environment Quantity of Life Birth Cancer Diagnosis Death Incidence Rates Stage Distribution Survival Rates Mortality Rates