CANCER SCREENING 2011 DELAWARE CANCER EDUCATION ALLIANCE STEPHEN S. GRUBBS, M.D. HELEN F. GRAHAM CANCER CENTER DELAWARE CANCER CONSORTIUM OCTOBER 5, 2011

SOURCES OF SCREENING RECOMMENDATIONS American Cancer Society (ACS) American Society of Clinical Oncology (ASCO) National Cancer Institute (NCI) U. S. Preventive Service Task Force (USPSTF) Delaware Cancer Consortium Early Detection and Prevention Committee

U.S. PREVENTIVE SERVICES TASK FORCE (USPSTF) Independent panel of private experts in prevention and PRIMARY CARE  16 Members, Primary Care (including RN), Mostly academic Sponsored by Agency for Health Care Research and Quality (AHRQ)  Public Law Section 915 mandates AHRQ to convene USPSTF  Supported by Evidence Based Practice Center

USPSTF RECOMMENDATIONS Intended for use in Primary Care setting Provides information about the evidence allowing clinicians to make informed decisions about implementation Grades:  A – Strongly Recommend  B – Recommend  C – No Recommendation For or Against  D – Recommend Against  I - Insufficient Evidence For or Against

CLINICIAN USE OF USPSTF GRADES A – Offer and Provide Service B – Offer and Provide Service C – Offer and Provide Service only if other considerations support individual use D - Discourage Use of Service I – Explain Uncertainty of Value of Services

RECOMMENDED CANCER SCREENS FOR AVERAGE RISK INDIVIDUAL (USPSTF GRADE) Recommended Screen Breast: 75 (I – 2009) Uterine Cervical: (A); > 65 years (D – 2003) Colorectal: 50 – 85 years (A); > 85 (D – 2008) Prostate: 75 (D -2008) Lung: ? Not recommended Screen Bladder: (I ) Oral: (I ) Ovary: (D – 2004) Pancreas: (D – 2004) Skin: (I ) Testicle: (D – 2011)

2009 USPSTF BREAST CANCER SCREENING RECOMMENDATIONS Routine Screening Mammogram Ages years – C  Biennial screening mammogram before age 50 should be an individual decision with patient balance of benefits and risk Biennial Screening Mammogram Ages – B Screening Mammogram > Age 75 – I Breast Self Exam – D Clinical Breast Exam (in addition to mammogram) – I Digital Mammogram and Breast MRI - I

DELAWARE CANCER CONSORTIUM BREAST CANCER SCREENING Standard Risk Women should receive Annual mammography starting at age 50 years Standard Risk Women ages 40 to 49 should be offered and encouraged to receive Annual mammography All women should be aware of the limitations of the screening Self Breast and Clinical Breast exam should be performed

Delaware Cancer Consortium Cervical Screening (PAP) AGE (years) Low Risk High Risk* <21 None 18 years 21 – 30 Every 2 years Annual >30 Every 2 years Annual Every 3 years if 3 negative PAPs or Normal PAP and negative HPV >65 Stop if 3 prior negative PAPs in last 10 years & Annual No abnormal in last 10 years *High Risk: early onset of sexual activity, multiple partners, history of STD

Delaware Cancer Consortium Colorectal Screening: Colonoscopy Average Risk: Every 10 years starting at age 50 years Family History of CA: Every 5 years starting at age 40 years Personal History of CA or Polyps: 3 years post polyp removal and then every 5 years Higher Risk (Familial Polyposis, HNPCC, Inflammatory Bowel Disease): Earlier Age of screening and more frequent. Stop Screening > 85 years old

Delaware Cancer Consortium Prostate Screening Promote Education for informed decision Average Risk: offer screening at age 50 years with informed decision High Risk: Encourage screening at age 40 years* or age 45 years** Age > 75 years: Screening less desirable but individualized. No screening if life expectancy < 10 years Screening: PSA + Digital Rectal Exam (DRE) every 1 to 2 years * Several 1 st degree relatives with Prostate CA ** African American, 1 st degree relative < 65, family or personal BRCA 1 or 2

NATIONAL LUNG SCREENING TRIAL Trial published in August, ,000 High Risk Participants (> 30 pack year smoker) Randomized to low dose Chest CT or CXR annually for 3 years Follow-up for additional at least 2 years post screening 20 percent reduction of Lung CA mortality by CT Screening Application to general population including cost effectiveness to be determined

DE CANCER SCREENING RATES (2010 BRFSS) Breast (mammogram): 81% of women > 40 years in last 12 months Cervical (PAP): 83% of women > 18 years in last 36 months Colorectal (colonoscopy): 74% of men & women > 50 years in last 5 years Prostate (PSA): 71% of men > 40 years in last 12 months CONGRATULATIONS DELAWARE !

RESEARCH CURES CANCER