Dr. Weal Habhab,MD,FRCPC Nephrology Consultant Nephrology Section Head King Faisal Specialist Hospital -Jeddah

Controversial, but it is reported to be higher in ESRD compare to general population Lancet,1999: international study indicated the standardized incidence ratio(SIR) of cancer to be 1.18 higher in ESRD patients. NDT,2011: study from Taiwan showed the SIR to be 1.4 in 4328 patients in 4.4 years follow up study.

The risk was higher in o Younger patients <35 o Female patients o In the first year of dialysis

Number of new cancer cases SIR95% CI All patients –1.4 Male –1.3 Female –1.7 Age at first dialysis 0–34 years – –54 years –3.9 55–65 years – years –0.8 Time after first dialysis Year –9.0 Year –4.2 Year –3.1 Year –2.2 Year –1.8 Years 6– –1.1 >Year –0.3

Acquired renal cystic disease Medication, CYP Infections, HBV and HCV Human papilloma virus

Controversial : o Infections o Prolonged chronic uremia impair T-cells and APC functions o Nutritional abnormality like Vit D deficiency and selenium deficiency

Bladder Kidney Liver Cervix Tounge

USRDS 2007, showed the risk of death from cancer among ESRD to be 7 deaths per 1000 patients. While cardiac arrest resulted in 38 deaths per 1000 patients at the same period.

Benefits High mortality from non- malignant causes

One study examined the benefits of mammography, PSA, sigmodiscopy and pap smear as screening tools among ESRD and showed, o The costs per unit of survival benefit conferred by cancer screening were 1.6 to 19.3 times greater among patients with ESRD compared with the general population o The net gain of life expectancy in patients with ESRD via these screening programs was calculated to be five days or less. Similar survival gains could be obtained by reducing the baseline ESRD mortality rate by 0.02 percent.

routine cancer screening in the ESRD population did not represent an efficient allocation of financial resources Similar findings were reported in a study evaluating the efficacy of breast and cervical cancer screening of Canadian women undergoing maintenance dialysis.

Colorectal cancer: In one series, the incidence of guaiac positive stools was three times higher in asymptomatic dialysis patients compared with non-ESRD controls. Nevertheless, the presence of a positive stool guaiac test in an asymptomatic individual with ESRD may permit the early discovery of a colorectal malignancy.

Prostate cancer o Screening with PSA still controversial in general population. o A higher incidence of prostate cancer among patients with ESRD has been reported. o Serum PSA levels do not appear to be affected by renal failure. o But it is not cost effective except in pretransplant evaluation

Cervical cancer o The standardized incidence ratio of cervical cancer among ESRD patients is approximately 2.5 to 4 times that in the normal population o This higher risk is due primarily to the increased presence of the human papilloma virus (HPV) in this patient population.

Cervical cancer o Pap smear screening beginning at age 21 years of age o HPV DNA testing and HPV vaccine, especially in transplant candidates o Yearly Pap test in those on transplant waiting lists and in patients with risk factors and long expected survival based on demographic factors and comorbid conditions affecting survival in ESRD.

Breast cancer o Yearly mammograms and breast examinations for women >40 years of age and on transplant waiting lists would be reasonable.

Renal cell carcinoma Acquired cystic disease is premalignant condition The incidence is 22% in patient on maintenance dialysis The incidence of RCC as complication of acquired cystic disease varies between 2-4% yearly screening for acquired cystic disease with US to be performed in patients who have been on dialysis for three to five years

Tumor markers: o The accuracy of other tumor markers in ESRD patients is unknown. o They are of high molecular weight and ineffectively removed by dialysis, giving highly false positive rate. o Still alpha- fetoprotein,PSA of high value

Practice guidelines and/or standards for cancer screening that have been developed in the general population are not necessarily applicable to patients with end-stage renal disease (ESRD). Cancer screening protocols are best implemented on an individual patient basis. Special consideration should be given to patients on transplant list Routine cancer screening is perhaps most inappropriate in patients with ESRD who are diabetic, white, or 65 years of age.