It is not uncommon for patients to present their physicians some sort of ailment. Whatever the cause for the visit, this becomes an excellent opportunity to discuss cancer screening recommendations. During this visit, the patient is probably wanting advice on what needs to be evaluated and the physician is attempting to define individual risks and screening needs based on the patients family history and present medical history.
The purpose of this dissertation is not to cover the screening recommendations for every disease process, but to be a guide for the more common cancer screening needs. It is imperative to note that screening needs may vary from person to person, depending on inherent risk factors, and that patient individual needs should be discussed with their physician. The following guidelines are intended to prompt discussion between patients and their physicians on an individual basis:
BREAST CANCER is one of the most feared cancer types for a multitude of reasons. The familial predisposition certainly adds to the anxiety of this dreaded cancer. Breast cancer compromises a triad of screening. There are no evidence–based recommendations on age to initiate self breast exams, but they should probably start in the early twenties. Self breast exams appear to remain equivocal as to its utility in reducing mortality; however, it continues to be encouraged for a multitude of reasons. In some circumstances, it is the point of identification. Clinical breast exam, in combination with mammography, does demonstrate improved detection of breast cancer at earlier stages, compared to clinical breast exam alone. Current mammographic recommendations are to begin at age forty, with a few exceptions, and clinical breast exams should be conducted yearly. Other modalities include ultrasonograghy which is used as an adjunct to palpable or mammographically identified masses. Magnetic resonance imaging has been used to aid in evaluation of palpable masses, and to better delineate between cancer and scar. A hot topic is that of digital mammography. It is important to note that both digital and film mammography utilize radiation, and the only difference is the medium on which they are recorded. There is some new evidence suggesting that digital mammography may have benefits in younger women in the setting of dense breasts typically found in pre–menopausal women. There is no distinct age to discontinue mammographic screening and should again be individualized.
CERVICAL CANCER screening is performed via a Papanicolao (Pap) test. Although there are no randomized controlled trials evaluating the Pap test, a large body of observational data have demonstrated its merit. Both incidence and mortality, have significant declines in Finland and Sweden over a twenty year period. Based on current recommendations Pap screening should initiate within three years of first vaginal intercourse, or twenty–one years of age. Evidence also suggests that the yearly interval could be extended to every two to three years with prior negative results. The National Cancer Institute also notes that women with prior hysterectomy for benign disease, have an extremely low prevalence of abnormal findings on Pap smears, suggesting a very low yield for Papanicolao screening. Guidelines are being formulated for this patient group, until then discussion with health care provider is recommended. Women age 65 to 70 with three normal Paps and no abnormal Pap in ten years may consider discontinuation of screening. It would be impossible not to mention HPV, human papilloma virus, in light of the recent controversies. Without further controversy, it safe to say that much benefit has come of the recent debates. Public awareness of the relationship between cervical cancer and HPV is now on the front page, hopefully reducing cervical cancer risk through awareness and education, if not through vaccination.
COLORECTAL CANCER, another cancer with familial predisposition, requires routine interval screening. Colon cancer, as many other cancer types, increases with age. The age for initiating screening has been determined to be age 50 for the general population. Screening includes a colonoscopy every ten years if initial screening is normal. Alternatives to a colonoscopy include Flexible Sigmoidoscopy every five years or an air contrast barium enema also at a five year interval if normal. All of the above modalities include yearly fecal occult blood testing. This test requires a stool specimen be submitted for occult blood examination. The age for initiation of screening and for the above interval are for individuals with normal risks. Family history of colon cancer may warrant earlier screening. New technology is being developed and newer screening tools may be in the future. The virtual colonoscopy which involves a micro camera passing through the gastrointestinal tract, remains controversial and is not yet part of the recommended screening armamentarium.
LUNG CANCER screening and testing poses a challenge for both patient and doctor. Thus far, current evidence has not demonstrated any screening tool to effectively reduce mortality from lung cancer. Prudence would dictate that presently the best mechanism of lung cancer reduction is to reduce environmental carcinogens, and to perform diagnostic work up when indicated.
PROSTATE CANCER screening recommendations vary. Some entities suggesting earlier screening via PSA and digital rectal exam in high risk groups, beginning at age forty, and others recommending the same screening to begin at age fifty. Medicare, the largest insurer, allows for PSA testing yearly after the age of fifty.
For more information, there are several key websites that present valuable cancer–related information –– The National Cancer Institute, PubMed, and the American Cancer Society.
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