1. Cancer Screening: Who, When and Why?
Alison Plotzke, CCPA Physician Assistant
Deanna Lautenbach, CCPA Physician Assistant Associate Clinical Professor

2. Disclosures We have no potential conflicts with this presentation
We have no relevant financial relationships to disclose
We will discuss both generic and brand name medications

3. Objectives
To become familiar with the cancer screening options available for patients in Ontario
To understand the benefits and potential risks involved with cancer screening
To understand who to screen for each cancer and when it is appropriate to start and stop screening

4. Background What does the term screening mean?
What types of cancer screening are available in Ontario?
Cancer screening refers to trying to detect cancer when symptoms are not present. It is import to differentiate this from investigation which can be done if a patient presents with symptoms that concern you that may have cancer.

5. Mary What type of screening is she due for?
What questions would you like to ask Mary

6. Cancer Screening Cervical Cancer: Last PAP 3 years ago Normal
Breast Cancer:
Mammogram 2 years ago: normal

7. Cervical Cancer Screening FAQ
When do you start:
Age 21 or when sexually active (whichever comes first)
When do you stop:
Age 69 as long as the past 3 PAPs have been normal
What if my patient has had a hysterectomy?
Full hysterectomy for benign disease do not require repeat PAPs
What if my patient is pregnant?
Continue on the same schedule (q3year as long as normal PAP)
What if my patient is transgender?
Transgender males who have retained their cervix should be screened according to the guidelines
Oncogenic strains of HPV

8. Mary’s Next PAP
Comes back showing LSIL

9. What if Mary’s PAP comes back abnormal?
LSIL Low grade squamous intraepithelial lesion
We use the Ontario Cervical Cancer Screening Guidelines to help us decide what to do with an abnormal Pap. The except on this slide is taken from this document. We know what Mary’s last PAP was normal. This PAP shows LSIL. Using these guidelines we know we need to repeat May’s PAP again in 6 months. If the repeat is normal we repeat it one more time at the 6 month interval and then she can return to normal screening. It is it abnormal we refer to colposcopy

10. What about vaccination?
National Advisory Committee on Immunization recommends giving the Gardasil vaccine to Females ages 9-45 and males ages 9-26.
Many gynecologists recommend giving it everyone, especially those with abnormal PAPs even outside of the recommended age range. Gardasil 9 protects against the 9 most common stains of the HPV virus: 6, 11, 16, 18, 31, 33, 45, 52, and 58
Merck Canada Inc. 2016
NACI recommends Gardasil 9 for females 9-45 and males 9-26.

11. Breast Cancer Screening FAQ
Who is high risk?
BRCA 1 and BRCA 2 carriers
First degree relatives of BRCA1/2 carries who have declined genetic testing
Have received chest radiation before age 30
High risk patients should be screened annually with mammogam and/or MRI between age 30-69
When should I screen my average risk patients?
q2 years between 50 and 74;lkj;klj;klj
What if my 45 year old patient requests a mammogram?
Optional between 40-49
Associated with more false positive test results
False positive test results lead to invasive and potentially harmful follow-up procedures
Anticipate a new guideline in 2018
Mention the Ontario Breast Screening Program

12. Breast Cancer Screening FAQ
What are the risks of Mammography?
Radiation
False Positives
Unnecessary testing and invasive procedures
Increased anxiety
What are the benefits?
Modestly reduces the number of deaths from breast cancer
Ages have the strongest benefit
Mammography is a type of x-ray so there is a small amount of radiation exposure for the patient.

13. Peter 58 year old male Healthy Last seen 9 years ago
Presenting to the doctor’s office “because his wife told him to”

14. Peter What type of screening is Peter due for?
What questions would you like to ask Peter?

15. Peter No history of colorectal cancer (CRC) screening No bowel changes
No constitutional symptoms
No family history of prostate cancer or CRC
No urinary symptoms
Non-smoker

16. CRC Screening FAQ Who do we screen?
Average risk individuals ages 50-74
How do we screen?
OBT q2 years OR
Flexible sigmoidoscopy q10 years
Who is high risk?
Previous colon cancer of polyps
Mention what happens in practice – colonoscopy
Mention that high risk patients do not adhear to the guidelines, they are for healthy asymptomatic patients only
Add FOBT picture and flex sig picture

17. CRC Screening FAQ
Peter chooses to use a FOBT kit which is sent home with him
He will place the kit in the mail when it is completed

18. Prostate Cancer Screening FAQ
How do we screen?
Controversy over the PSA and DRE
Deanna to send Alison Jason’s paper

19. Prostate Cancer Screening FAQ
Screening programs for prostate cancer are a widely debated topic
There is considerable inconsistency in current guidelines
Controversy over the PSA and DRE
Deanna to send Alison Jason’s paper

20. The Guidelines Canadian Task Force on Preventative Health
We recommend not screening for prostate cancer with the PSA test
Cancer Care Ontario (CCO)
Given the potential harms of screening, including over-diagnosis and over-treatment, CCO does not support an organized, population-based screening program for prostate cancer
Canadian Urological Association
Prostate cancer screening should be offered to all men 50 years of age with at least a 10-year life expectancy
American Academy of Family Physicians
Do not routinely screening for prostate cancer using a PSA test or DRE
American Urological Association
Offer PSA screening for prostate cancer only after engaging in shared decision making
Controversy over the PSA and DRE
Deanna to send Alison Jason’s paper
Adapted from Am Fam Physician, 2015; Canadian Task Force, 2014; Cancer Care Ontario, 2015

21. Risks and Benefits What are the risks of prostate cancer screening?
What are the benefits of prostate cancer screening?
DRE low sensitivity, low specificity, high examiner bias

22. Prostate Cancer Screening FAQ
Among men ages 55 to 69 who do not get screened, the risk of dying from prostate cancer is 6 in 1,000.
With regular PSA screening, the risk of dying from prostate cancer among men aged 55 to 69 may be reduced to 5 to 1,000.
ISN’T IT BETTER TO GET SCREENED THAN TO DO NOTHING?
Screening with the PSA ofter leads to further testing, which carries with it its own serious risks and problems.
For example, a biopsy involves a number of potential harms such as infection, blood in the urine, or even death.
Additionally, if testing leads to treatment, such as a prostectomy (removal of the prostate gland), the chances of urinary incontinence and erectile dysfunction significantly increases. Other short term post-surgical complications include infections, additional surgeries and blood transfusions and death.
Canadian Task Force, 2014

23. Bottom Line PSA Not useful as a screening tool DRE
Controversy over the PSA and DRE
Deanna to send Alison Jason’s paper

24. Summary Cervical Cancer PAP every 3years Ages 21-69 Breast Cancer
Mammogram every 2years
Ages 50-74
Colorectal Cancer
FOBT ever 2 years or flex sig every 10 years
Ages 50-74
Prostate Cancer
Don’t screen
Controversy over the PSA and DRE
Deanna to send Alison Jason’s paper

25. Thank you