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Transcript of Cancer detection
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CANCER DETECTION AND SCREENING
DR. ADONIS A. GUANCIA
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7
7.2
8.2
10.7
11.2
11.4
12.5
12.5
13.6
14.8
32.4
0 5 10 15 20 25 30 35
Nasopharynx
Thyroid Gland
Larynx
Gastric
Skin
Rectal
Liver
Lymph Node
Colon
Prostate
Lung
Top Ten Leading Cancer Site in Male 2000 - 2009
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11.3
16.5
16.6
18.8
20.7
21.2
22.8
23.3
24.1
119.9
0 20 40 60 80 100 120
Lymph Node
Thyroid Gland
Prostate
Corpus Uteri
Lung
Head and Neck
Ovary
Cervix
Colorectal
Breast
Ten Leading Cancer Sites by Gender Adjusted 2000 - 2009
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Five-year Relative Survival (%)* during Three Time Periods By Cancer Site
*5-year relative survival rates based on follow up of patients through 2003. †Recent changes in classification of ovarian cancer have affected 1996-2002 survival rates.Source: Surveillance, Epidemiology, and End Results Program, 1975-2003, Division of Cancer Control andPopulation Sciences, National Cancer Institute, 2006.
Site 1975-1977
1984-1986
1996-2002All sites 50 53 66Breast (female) 75 79 89Colon 51 59 65Leukemia 35 42 49Lung and bronchus 13 13 16Melanoma 82 86 92Non-Hodgkin lymphoma 48 53 63Ovary 37 40 45Pancreas 2 3 5Prostate 69 76 100Rectum 49 57 66Urinary bladder 73 78 82
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Breast Cancer Screening
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Effective Screening Test Disease incidence should be high Diagnosed at early stage but
without any signs Early diagnosis and treatment
should be more effective than late treatment
Benefit of early treatment should be higher than the cost and harmfulness of screening
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Breast Cancer: Risk Factors (Unchangeable)
Being a woman
Age
Genetic factors - mutations in BRCA1 or BRCA2; 50-60% of women inheriting a BRCA1 mutation from either parent will have breast cancer by age 70
Family history of breast cancer (not related to BRCA mutations)
Personal history of hyperplastic breast disease
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Breast Cancer Risk Factors (Unchangeable)
Personal history of breast cancer
Race: incidence is higher in Caucasian compared with African-American, Hispanic or Asian women
Radiation treatment: chest irradiation as a child/young woman can significantly increase risk of developing breast cancer
Menstrual history: early menarche (<12 yr) or late menopause (>50yr) has some association with increased risk. Also nulliparous, or first childbirth at >30 yrs.
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Breast Cancer Risk Factors Lifestyle Associated
Oral contraceptives - remains controversial
Hormone replacement therapy - >5 years of therapy with combined estrogen and progesterone may increase risk
Not breast feeding
Diet and obesity; physical activity
Smoking - still being investigated
Alcohol - 2-5 drinks/day can increase risk x 1.5 over non-drinkers.
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Does Mammography Reduce Breast Cancer Mortality?
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Mortality Reduction in Screening Patients
Study Age Mortality reduction (%)
HIP 40-64 24Malmö 45-69 19Sweeden 40-74 32Edinburgh 45-64 21Stockholm 40-64 26Canada-1 40-49 -3Canada-2 50-59 -2Gothenburgh39-59 16
All studies 39-74 24
CA Cancer J Clin 2003; 53:141-169
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At What Age Mammography Screening Should Start?
All women starting at 40 years old should be screened with mammography
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What Intervals Mammographic Screening Should be Done?
EVERY YEAR
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Digital Mammography Provide equivalent detection level
compared with conventional mammography
Offers a lower average dose of radiation
Easier access to images and computer-assisted diagnosis
Superior in pre and postmenopausal women with dense breast and women under the age of 50
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Breast US
It is more subjective than
mammography Could not detect
microcalcifications Sonographic contrast is week
between tumor and adipous tissue Documentation is problematic Not useful for screening
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Breast MRI
Expensive Higher sensitivity with lower
spesificity Not safe for detection of
microcalcification Useful for additional screening
method for high risk women having mammography
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MRI for Evaluation of the Breast
Highly sensitive but high false positive rate
Useful for screening BRCA patients May be useful in staging known
breast cancer May become an important screening
modality
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Other Imaging Modalities
Tc99m sestamibi scan (Miraluma) Tomosynthesis (variation of
mammogram)
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Breast Cancer Risk Factors
Greatly increased risk RR>4.0 Inherited genetic mutations for breast
cancer ≥ 2 first degree relatives with breast
cancer diagnosed at early age Personal history of breast cancer Age >65 (increasing risk with increasing
age to 80)
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Screening for High Risk Women
Mammographic screening should be start at 30 years of age (rarely before this age)
Screening interval can be shorter (e.g. 6 mos)
MRI can be added US can be added
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Screening Guidelines for the Early Detection of
Breast Cancer, American Cancer Society
Yearly mammograms are recommended starting at age 40.
A clinical breast exam should be part of a periodic health examination, about every 3 years for women in their 20s and 30s. Asymptomatic women aged 40 and older should continue to undergo a clinical breast exam, preferably annually*.
Beginning in their early 20s, women should be told about the benefits and limitations of breast-self examination. Women should know how their breasts normally feel and report any breast changes promptly to their health care providers.
Beginning at age 40 years, annual CBE should be performed prior to mammography
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Cervical Cancer Screening
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Cervical Screening
incidence decreased > 50% the past 30 years American Cancer Society estimates 11,270
new cases of cervical cancer in the United States in 2009, with 4,070 deaths from the disease
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Cervical Screening
should begin at 21 years of age Screening done regardless of the age of onset
of sexual intercourse
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Cervical Screening
Even at a high rate of infection with HPV in sexually active adolescents,
invasive cervical cancer is very rare in women younger than 21 years old.
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Cervical Screening
Cervical cytology screening :
21–29 years, every 2 years using conventional or liquid-based cytology.
30 years and older with three consecutive cervical cytology test results that are negative for CIN and malignancy may be screened every 3 years
> 65 years old no testing.
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Cervical Screening
May require more frequent cytology screening Women who are infected with human
immunodeficiency virus (HIV) Women who are immunosuppressed (such as those
who have received renal transplants) Women who were exposed to diethylstilbestrol in
utero Women previously treated for CIN 2, CIN 3, or
cancer
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Cervical Screening
It has been demonstrated, however, that the rate of dysplasia decreases as the number of sequential negative Pap test results increases
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Cervical Screening
Formal cost-effective analysis of data from this national program showed that the most cost-effective strategy for cervical cancer screening is cytology testing no more often than every 3 years in women with prior normal screening test results
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Cervical Screening
May discontinue cytology screening with three or more negative cytology test results in a row and no abnormal test results in the past 10 years.
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HPV
70 % of cervical cancer result from infection with HPV 16 and 18
90% of Genital wart are caused by 6 and 11
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HPV vaccination guidelines
Organization/Nation Start Vaccine Catch Up
ACIP 11-1213-2 6
American College of Ob-Gyn 9-26
American Cancer Society 11-18None
World Health Organization 9-13
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Future ?
Anal Pap smears 4000 cases of anal cancer in women in 2003
and in contrast to cervical cancer the rates are increasing
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Lung Cancer Screening
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Lung Cancer High Risk Factors
55 – 74: > 30 pack years smoking historyceased smoking < 15 years
> 50 years > 20 pack year smoking historyone additional risk factor
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Prevalence of Stage I Lung Cancer in CT Screening Trials
% Stage II-ELCAP 85Mayo69Turino 73
Randomized TrialsLSS 43Depiscan 38DANTE 57
NELSON 64
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Drawbacks or Limitations to CT Screening for Lung Cancer
Many nodules that require follow-up Potential Psychological Impact Surgery for Benign Disease Lung Cancer Deaths in Screened
Participants Interval Cancers (failure of screening) Potential Overdiagnosis Cases
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PLCO trial
Prostate Lung Colo-rectal Ovarian Cancer Screening Trial
Determine effects of screening in mortality among men and women aged 55 to 74
Completed in 2005
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PLCO Final Results Randomized 154,900 Individuals
Age 55-74 to CXR or Usual Care (4 years)
Screening Adherence Was 86% Baseline and 79-84% Yearly– 11% Screening Done in Usual Care
JAMA 2011; 306: 1865-1873
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PLCO: Chest X-ray vs. Usual Care
JAMA 2011; 306: 1865-1873
• Annual Screening with CXR (4 years) Did Not Reduce Lung Cancer Mortality Compared to Usual Care.
• In Subset Analysis of NLST Eligible Participants, There Was No Mortality Reduction in the Chest X-ray Screened Arm.
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Lung Cancer Risk Predictions:PLCO
Incidence Rate of Lung Cancer: per 10,000 Person Years on Control Arm (Intervention) Never Smoker: 2.5 (3.3) Former Smoker: 18.7 (19.3) Current Smoker: 71.4 (79.9)
Tammemagi et al. JNCI 2011; 103: 1058-68
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National Lung CancerScreening Trial (NLST)
CP1066773-57
SmokerFormer smoker30 pk yrAge 55-74
SmokerFormer smoker30 pk yrAge 55-74
40,000PLCO40,000PLCO
10,000ACRIN10,000ACRIN
RandomizedRandomized
Low-dose fast spiral CTLow-dose fast spiral CT
CXRCXR
YearsYears
00 11 22
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National Lung Cancer Screening Trial
August 2002 - April 2004 Enrollment Three rounds of screening through September
2007 Followed for Events through December
31, 2009 Median F/U = 6.5 years; Max 7.4 years
Adherence to Screening 95% on CT arm: 93% on CXR Average annual rate of CT in CXR arm was
4.3%
NEJM 2011 epub June 29 NEJM.org
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National Lung Cancer Screening Trial
CT CXRAbnormal Screen 24.2% 6.9%
False Positive 96.4% 94.5%
Clinically Significant other abnormalities 7.5% 2.1%
Total Lung Cancers 1,060 941
LC per 100,000 person - years 645 572
NEJM 2011 epub June 29 NEJM.org
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National Lung Cancer Screening Trial
Diagnostic F/U of Positive Screen CT CXR• Imaging 58% 78%
– PET 8% 8%
• FNA 1.8% 3.5%
• Bronchoscopy 3.8% 4.5%
• Surgical: Mediastinoscopy, Thorascopy, or Thoracotomy 4.0% 4.8%
NEJM 2011 epub June 29 NEJM.org
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National Lung Cancer Screening Trial
CT CXRTotal Lung Cancers 1,060 941
Screen-detected Lung Cancer 649 279
Lung Cancer after Negative Screen 44 137
Either Missed Screening or After Screening Phase 367 525
NEJM 2011 epub June 29 NEJM.org
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National Lung CancerScreening Trial
NEJM 2011 epub June 29 NEJM.org
• 20% Mortality Reduction from Lung Cancer
• 6.7% All Cause Mortality Reduction
• 320 Persons Needed to be Screened with LDCT to Prevent One Death
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NCCN Guidelines Screening with LDCT is
Recommended for High-Risk Individuals Meeting the NLST Criteria (2A)
Also Recommend Screening for (2B)– Age >50 Years and ≥20 Pk Years and One
Additional Risk Factor Other Than Second Hand Smoke
NCCN.org accessed 11/8/2011
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Lung Cancer Susceptibility Locus Identified
15 q 251) Amos et al. Nature Genetics 2008; 40:616-
22.2) Hung et al. Nature 2008; 452:633-37.
15 q 241) Thorgeirsson et al. Nature 2008; 452:638-
42. (Associated with nicotine dependence, lung cancer and vascular disease)
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Potential Biomarkers for Screening
Airway epithelial cells Gene expression profiling Chromosomal aneusomy – FISH Gene methylation
Blood biomarkers Serum proteins Autoantibodies to tumor antigens Gene expression profiles in PBMC
Breath analysis of VOC Urine markers of carcinogens
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Early CDT-Lung Blood Test 573 case/control study with match for
age sex and smoking Sensitivity 40%; Specificity 90%; Accuracy
88% Detect some cancers 3-5 years in advance
of symptoms Autoantibodies to 6 cancer antigens
P53; NY-ESO-1; CAGE; GBU4-5; Annexin 1 and SOX2
Murray et al Ann Oncol ePub Feb 2010 and ASCO posters 2010
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New York Times
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Volatile Compounds in Exhaled Breath Analysis of Lung Cancer Patients
1/3 of compounds detected by solid phase microextraction were hydrocarbons Aromatic hydrocarbons Alcohols Aldehydes Ketones Esters Sulfur compounds Nitrogen containing compounds Halogenated compounds
Ligor M et al. Clin Chem Lab Med 2009; 47:550-60.
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Prostate Cancer Screening
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ACS Screening Recommendations
Prostate Cancer Early Detection Guidelines
> 50 years with at least a 10 year life expectancy should receive information regarding possible benefits and limitations of finding and treating prostate cancer early, and should be offered both the PSA blood test and digital rectal exam annually
Men in high risk groups (African Americans, men with close family members---fathers, brothers, or sons---who have had prostate cancer diagnosed at a young age) should be informed of the benefits and limitations of testing and be offered testing starting at age 45
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.
Types of Tests
Diagnostic Tests - Tests done because of an identified problem (disease is suspected)
Screening Tests -Test done on people who have no symptoms of disease
There is widespread agreement on the use of diagnostic tests for prostate cancer
Screening for prostate cancer is much more controversial
What are Tests for Prostate Cancer?
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Changes in the PSA Era
.
Tyrol, Austria
42% mortality reduction
Olmstead County, Minnesota
22% mortality reduction
SEER
Decreased mortality in white men
Department of Defense
Increased early stage disease
Does screening for Prostate Cancer save lives?
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.
Prostate cancer death rates have fallen during the PSA era, but it is not clear this is primarily due to screening
Other possible reasons for this decline:
Disease is found earlier because of
increased awareness
utilization of diagnostic PSA testing
Improved treatments
Does screening for Prostate Cancer save lives?
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.
False negative results
False positive results
Overdiagnosis
Does screening for Prostate Cancer save lives?
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.
False negative results� PSA and DRE “normal”, but cancer is
present� May lead to false reassurance, delayed
diagnosis
Research has shown that no cut-off value of PSA is completely reliable to rule-out cancer� Prostate Cancer Prevention Trial end of
study biopsies found cancer in some men with PSA less than 1.0 ng/ml
Does screening for Prostate Cancer save lives?
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Population Screening with PSA
4.0+
PSA 4+ 7.6%Positive biopsy 25%High grade 19%
Screen 10,000 Men
PSA 4+ 760Cancer 190High grade 36
PSA <4 9240Cancer 1386 High grade 208“Normal PSA” 92.4%
Positive biopsy 15%High grade 15%
<4.0
PSASEER, PCAW, Prostate Cancer Prevention Trial Data
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.
False negative results
False positive results PSA and/or DRE abnormal, but no cancer
found
Can lead to worry, additional tests, and increased costs
Does screening for Prostate Cancer save lives?
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.
False negative results
False positive results
Overdiagnosis Some (many?) cancers found by screening
grow very slowly and will never cause problems
Does screening for Prostate Cancer save lives?
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New Findings in Screening
.
Results from 2 major, long-term studies reported this year – their findings conflict
ERSPC (European Randomized Screening for Prostate Cancer)
PLCO (Prostate, Lung, Colon and Ovarian)
Does screening for Prostate Cancer save lives?
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ERSPC
Began in 1991 in seven European countries
162,000 men aged 55 to 69 randomized to screening vs usual care
Median follow-up about nine years
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ERSPC
Findings More cancers detected with screening
5990 cancers in screening group 4307 cancers in control group
Fewer prostate cancer deaths in screening group
261 deaths in screening group 363 deaths in control group
Conclusion: 20% lower prostate cancer deaths in screening group
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ERSPC Multiple concerns/questions:
Minimal-to-no participation of men of African origin Different screening and follow-up protocols
Different PSA levels and DRE usage Variable treatment and outcomes (quality questions)
To prevent one prostate cancer death 1410 men screened 48 men treated (with attendant risks, side-effects,
complications)
Bottom line Screening every 4 years, with PSA threshold of 3
ng/ml may decrease chance of prostate cancer death Unclear how this correlates to current U.S. pattern of
annual screening with different PSA “triggers” (2.5 – 4.0 ng/ml)
High level of overdiagnosis and overtreatment with this approach (although these numbers are likely to go down after longer follow up period)
Relevance of findings to African American men unclear
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PLCO
Began in 1993, ten U.S. Centers 73,000 men aged 55 to 74
randomized to screening annually vs routine follow-up
Median follow-up about ten years
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PLCO
Findings At 7 years, screening found more cases of
cancer 2,820 prostate cancers in annual screening group 2332 cases in “usual care” group
More prostate cancer deaths in screening group 7 years: 50 deaths among annually screened compared
with 44 in usual care group 10 years: 92 deaths in annually screened vs 82 in usual
care Conclusion – No mortality benefit with screening
Prostate cancer deaths similar in both groups Overall death rate slightly higher in screened (not
statistically significant)
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PLCO Questions/concerns with study
44% of men had at least one PSA test prior to study May have excluded more aggressive prevalent cancers Selectively included men with prostate cancers not
detected by PSA screening (bias against showing a screening effect)
Many men in the “usual care” group were screened during the course of the study Initially powered for 20% contamination, later revised to
38% PSA screening in control group : 40% first year; 52% by
year 6 Less than half of those with a positive screen result had
a biopsy Insufficient African American participation (< 5%) to
allow specific analysis of outcomes in this group Bottom line – no difference in death rates at 10
years between intensively screened and less-intensively screened men
Relevance of these findings to African American men is unclear
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Treatment OptionsNew Findings in Treatment
JAMA, September 2009
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Watchful Waiting
Study published September 2009 14,500 men aged 65 + with localized
prostate cancer No active treatment for at least 6 mos
following prostate cancer diagnosis At 10 years, 9% of men had died of prostate
cancer 1017 men died of prostate cancer 5721 men died of other causes 7420 men still alive
Approximately 11% African Americans in study population, but authors did not report findings separately for this group
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• PSA screening detects cancers earlier.
• Treating PSA-detected cancers may be more effective, but this is uncertain.
• PSA may contribute to the declining death rate but the extent is unclear
• False positives are common. • Overdiagnosis and
overtreatment is a problem, but magnitude is uncertain.
• Treatment-related side effects are fairly common.
Potential Benefits
Summary
Potential Harms
Bottom line: Uncertainty about degree of benefits and magnitude of harms
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Screening Recommendations
Current ACS Screening Guidelines
Men age 50 and over with at least a 10 year life expectancy should receive information regarding possible benefits and limitations of finding and treating prostate cancer early, and should be offered both the PSA blood test and digital rectal exam annually
Men in high risk groups (African Americans, men with close family members---fathers, brothers, or sons---who have had prostate cancer diagnosed at a young age) should be informed of the benefits and limitations of testing and be offered testing starting at age 45
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Colon Cancer Screening
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Average risk Colon cancer
50 years of age No history of adenoma or colon cancer No history of inflammatory bowel disease Negative family history
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Increased risk for Colorectal Cancer
Adenoma/sessile serrated polyp History of colorectal cancer Inflammatory bowel disease Positive family history
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Colorectal Cancer high risk syndromes
Lynch Syndrome (hereditary nonpolyposis colorectal cancer)
Polyposis syndrome Classical familial adenomatous polyposis Attenuated Familial Adenomatous Polposis MUTYH-Associated Polyposis Peutzh Jeghers Syndrome Juvenile Polyposis Syndrome Serrated Polyposis Syndrome
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Colorectal CancerSporadic (average risk) (65%–85%)
Familyhistory(10%–30%)
Hereditary nonpolyposis
colorectal cancer (HNPCC) (5%)Familial
adenomatous polyposis (FAP)
(1%)
Rare syndrom
es (<0.1%)
CENTERS FOR DISEASE CONTROLAND PREVENTION
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Normal to Adenoma toCarcinoma
Human colon carcinogenesis progresses by the
dysplasia/adenoma to carcinoma pathway
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Benefits of Screening
Cancer Prevention Removal of pre-cancerous polyps prevent
cancer (unique aspect of colon cancer screening)
Improved survival Early detection markedly improves chances
of long term survival
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ACS 2003 CRC Prevention and Early Detection Recommendations
Fecal Occult Blood Testing (FOBT) Guaiac
Immunochemical
Flexible Sigmoidoscopy (FSIG)
FSIG + FOBT
Colonoscopy
Double Contrast Barium Enema (DCBE)
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The 2008 CRC Guidelines Update was a Joint Effort of 5 Organizations
American Cancer Society
U. S. Multi-Society Task Force on Colorectal Cancer American Gastroenterological Association
American College of Gastroenterology
American Society of Gastrointestinal Endoscopists
American College of Radiology
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CRC Screening Guidelines: What Else is New?
Two new tests recommended: stool DNA (sDNA) and computerized tomographic colonography
(CTC) – sometimes referred to as virtual colonoscopy
The guidelines establish a sensitivity threshold for recommended tests
The guidelines delineate important quality-related factors for each form of testing
The full article can be accessed at:http://caonline.amcancersoc.org/cgi/content/full/CA.2007.0018v1
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2008 CRC Screening GuidelinesBeginning at age 50, both men and women at average risk for developing colorectal
cancer should use one of the screening tests below:
Tests That Detect Adenomatous Polyps and Cancer
Flexible sigmoidoscopy (FSIG) every 5 years*, or
Colonoscopy every 10 years, or
Double contrast barium enema (DCBE) every 5 years*, or
CT colonography (CTC) every 5 years*
Tests That Primarily Detect Cancer
Annual guaiac-based fecal occult blood test (gFOBT) with high test sensitivity for cancer *, ** or
Annual fecal immunochemical test (FIT) with high test sensitivity for cancer*,** or
Stool DNA test (sDNA), with high sensitivity for cancer*, interval uncertain
* Colonoscopy should be done if test results are positive.** For gFOBT or FIT used as a screening test, the take-home multiple sample method should be used.
gFOBT or FIT done during a digital rectal exam in the doctor's office is not adequate for screening.
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2008 CRC Guidelines Continue to Emphasize Options Because:
Evidence does not yet support any single test as “best”
Uptake of screening remains disappointingly low Individuals differ in their preferences for one test
or another Primary care physicians differ in their ability
to offer, explain, or refer patients to all options equally
Access is uneven geographically, and in terms of test charges and insurance coverage
Uncertainty exists about performance of different screening methods with regard to benefits, harms, and costs (especially on programmatic basis)
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FOBT Sensitivity: Take Home vs. In-Office
Sensitivity of Take Home vs. In-Office FOBT
Sensitivity
FOBT method(Hemoccult II)
All Advanced Lesions
Cancer
3 card, take-home 23.9 % 43.9 %
Single sample, in-office 4.9 % 9.5 %
Collins et al, Annals of Int Med Jan 2005
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Stool DNA Test (sDNA)
Rationale Fecal occult blood tests
detect blood in the stool – which is intermittent and non-specific
Colon cells are shed continuously
Polyps and cancer cells contain abnormal DNA
Stool DNA tests look for abnormal DNA from cells that are passed in the stool*
*All positive tests should be followed with colonoscopy
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Performance Characteristics of Stool DNA in the Detection of CRC
Three versions of the previously marketed sDNA test have been evaluated Version 1 (K-ras, APC, p53,BAT-26, DIA) was
evaluated in the Imperiale trial
Version 1.1 (K-ras, APC, P53), PreGen-Plus is the currently marketed test
Version 2 (Vimentin only, or Vimentin + DIA) is currently under evaluation and is expected to enter the market in Fall 2008
Earlier and more recent tests were evaluated in smaller, mixed populations
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Performance Characteristics of Stool DNA in the Detection of CRC
Testing evaluates stool for the presence of altered DNA in the adenoma-carcinoma sequence
No dietary restrictions No stool sampling (utilizes
the entire stool) Several studies suggesting
strong patient acceptance Testing interval uncertain Uncertainty about the
meaning of false positives
Study with One-Time Testing (v)
Sensitivity for Cancer
Ahlquist, et alGastro, 2000 (1) 91%
Imperiale, et alNEJM, 2004 (1) 51.6%
Syngal, et. alCancer, 2006 (1) 63%
Whitney, et alJ Mol Diagn, 2004 (1.1)
70%
Chen, et alJNCI, 2005 (2) 46%
Itzkowitz, et alDDW-AB, 2006 (2) 88%
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Stool DNALimitations
Misses some cancers
Sensitivity for adenomas with current commercial version of test is low
Technology (and test versions) are in transition
Costs much more than other forms of stool testing (approximately $300 - $400 per test)
Not covered by most insurers
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Stool DNALimitations (cont.)
Appropriate re-screening interval is not known
Not clear how to manage positive stool DNA test if colonoscopy is negative
FDA issues
Test availability
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CT Colonography (CTC)
CTC Image Optical Colonoscopy
Courtesy of Beth McFarland, MD
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CT Colonography
Rationale
Allows detailed evaluation of the entire colon
A number of studies have demonstrated a high level of sensitivity for cancer and large polyps
Minimally invasive (rectal tube for air insufflation)
No sedation required
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CTC vs. Optical Colonoscopy: Meta-Analyses
Halligan 2005, Mulhall 2005
Polyp Size
CTC performance
>10mm 6-9 mm Cancer
Pooled Sensitivity
85-93% 70-86% 85.7%
Pooled Specificity
97% 86-93% ----
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CTC vs. Optical Colonoscopy: Sensitivities for All Polyps
Pickhardt et al, NEJM 2003
Polyp Size
>10mm >8mm >6mm
CTC 92.2% 92.6% 85.7%
Colonoscopy 88.2% 89.5% 90.0%
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CTC - Extra-Colonic Findings
Most have limited clinical impact, but some are important:
Asymptomatic cancers outside of colon and
rectum
Aortic aneurysms
Renal and gall bladder calculi
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CT Colonography Limitations Requires full bowel prep (which most patients find
to be the most distressing element of colonoscopy)
Colonoscopy is required if abnormalities detected,
sometimes necessitating a second bowel prep Steep learning curve for radiologists Limited availability to high quality exams in many
parts of the country Most insurers do not currently cover CTC as
a screening modality
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CT Colonography Limitations Extra-colonic findings can lead to
additional testing (may have both positive and negative connotations)
Questions regarding: Significance of radiation exposure
Management of small polyps
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2008 USPSTF Guidelines
U.S. Preventive Services Task Force, Ann Intern Med 2008