Dyspepsia Ilan Lenga, former CMR and David Cherney, former CMR MSH AIMGP 2004.
CANCER SCREENING PART I AIMGP Seminar Series January, 2004 Joo-Meng Soh Edited by Gloria Rambaldini.
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Transcript of CANCER SCREENING PART I AIMGP Seminar Series January, 2004 Joo-Meng Soh Edited by Gloria Rambaldini.
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CANCER SCREENINGPART I
AIMGP Seminar Series
January, 2004
Joo-Meng Soh
Edited by Gloria Rambaldini
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CASE #1Your father has just turned 50 years old and his family doctor is recommending prostate cancer screening tests.
He has been reading the newspapers and came across the following article:
Toronto Star, Dec. 31, 2001
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CASE #1
a) No ... the health care system can’t afford itb) Yes – go for a Digital Rectal Examc) Yes – go for a PSA testd) Yes – go for a DRE and a PSAe) Don’t know – I haven’t been through AIMGP
Cancer Screening Guidelines Part I yet....
He asks you if he should be screened and what tests he should undergo...
You tell him:
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OBJECTIVES• Understand the concept of cancer
screening and the controversies surrounding this topic
• To learn the Canadian screening guidelines for Prostate and Cervical cancer
• To be aware of other cancer screening guidelines available
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Principles of Cancer Screening
• Screening of asymptomatic individuals to detect early cancers which may be curable
• Use of diagnostic tests of high sensitivity• Diagnostic tests are suitable to the patient• Natural history of disease can be
changed by intervention• Proposed early treatment should be
beneficial and not harmful to the patient
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Guidelines Available
Website: http://www.ctfphc.org
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Guidelines Available
http://www.hc-sc.gc.ca/hppb/healthcare/pubs/clinical_preventive/
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Prostate Cancer• 2nd most frequent cause of cancer-
related deaths among males • Rapid rise in incidence over age 60• Lifetime risk of developing prostate
cancer=16 %; risk of dying 3%• Many cases not clinically evident:
– at autopsy prostate CA in one-third of men<80, two-thirds men >80
• Prostate CA grows slowly: most men die of other causes
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Prostate CancerCanadian Statistics:
• Estimated New cases for 2001: 17 800
• Estimated Deaths for 2001: 4300
Canadian Cancer Statistics 2001 Website: http://66.59.133.166/stats/maine.htm
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Options for Screening
• Digital Rectal Examination
• Prostate-Specific Antigen (PSA)
• Trans-Rectal UltraSound (TRUS)– not recommended as a screening tool
primary use is to guide biopsies
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Digital Rectal Examination• Sensitivity Poor
• 40-50% of cancers are out of reach
• Inter-rater reliability low-moderate
• PPV 15-30%, NPV even lower
NOTE:
Since Gold Standard Test is prostatectomy or extensive biopsy, Sens. & Spec. cannot be accurately determined Positive and Negative Predictive Values are used instead
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Prostate Specific Antigen• Produced by epithelial cells of prostate• Levels > 4.0 ng/mL “suspicious”• Physicians' Health Study (22,000
men with long-term follow-up)– sensitivity of a single baseline PSA
>4.0 ng/mL approximately 73% for any prostate cancer
– 87% for aggressive cancers – Canadian data suggests high false
positive rates
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Prostate Specific Antigen• Positive Predictive Value:
– If PSA 4-10: 22%– If PSA >10:40-60%
• Conditions which increase PSA levels– BPH, DRE– TRUS, Biopsy– Prostatic infection, recent ejaculation
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Prostate Specific Antigen
• As PSA levels increase:– Odds of cancer increase– Odds of extra-capsular or metastatic
disease increase– Odds of “cure” decrease if it is cancer
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PSA - Pros
• Detect cancer early, while still curable
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PSA - Cons• No evidence for a
reduction in morbidity or mortality
• Positive test may result in unnecessary tests and treatments
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PSA – Cons• Treatment of early stage cancer may
have no impact on overall survival
• Even combined with DRE, PPV not substantially higher (20%)
• Possible harms with treatment (prostatectomy or radiation therapy):
– impotence, urinary incontinence,
peri-operative morbidity/mortality
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Prostate Screening Guidelines Variety of Recommendations exist:
AAFP American Academy of Family Physicians ACP-ASIM American College of Physicians-American Society of
Internal Medicine ACS American Cancer Society AUA American Urological Association AMA American Medical Association CTFPHC Canadian Task Force on Preventive Health Care USPSTF U.S. Preventive Services Task Force
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Recommendations• Canadian Task Force on Preventative
Health Care:
“Based on the absence of evidence for effectiveness of therapy and the substantial risk of adverse effects of associated with such therapy and the poor predictive value of screening tests, there is at present insufficient evidence to support wide-spread initiatives for the early detection of prostate cancer.”
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Recommendations
ACP-ASIM gives a pragmatic compromise:
“Physicians should describe potential benefits and known harms of screening, diagnosis, and treatment; listen to the patient’s concerns, then individualize the decision to screen”
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Counseling Patients• Prostate Cancer is an important health
problem
• Benefits of Screening are unproven
• DRE & PSA can have false positives and false negatives
• Probability of further invasive evaluation is high (around 15%)
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Counseling Patients
• If a tumour is found, aggressive therapy (along with its risks/complications) is necessary to realize any benefit
• Early detection may save lives and avert future cancer-related illness
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Counseling Patients• Ministry of Health and Longterm Care
provides information for patients:
• Available through ICES Website:http://www.ices.on.ca/
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Back to the Case• Review the data
• Discuss the options with the family doctor
• Then make an informed decision on whether or not to undergo screening
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CASE #262 y.o. widowed female with two healthy children
She says, “I’m 62 years old now and no longer sexually active. My last two PAP tests were negative.” She asks ”Do I really need another one? Will this ever end???”
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CASE #2You tell her:
a) No – you are too old for it now
b) No – because your last two were negative
c) Yes – every year
d) Yes – every 3 years
e) I don’t know yet.....but I’ll tell you in 5 minutes (after the end of this
seminar)
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Guidelines Available
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Cervical Cancer• 11th most common cancer among
women in Canada
• Canada, 1993:– 1300 women developed cervical cancer– 400 women died of the disease
Canadian Statistics:
• Estimated New cases (2001): 1450
• Estimated Deaths (2001): 420
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Cervical Cancer• Risk Factors
– early age at first sexual intercourse (<17y/o)– multiple sexual partners (>2)– smoking– low socioeconomic status– HPV Infection (Types 16, 18, 31, 39, 45, 56, 58,
59, 68)– Hx STDs– Hx other lower genital tract neoplasia– Radiation– Immunosuppression– OCPs
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Cervical Cancer Screening• Papanicolaou Smear Test
• High False Neg. Rate: up to 25%– Sampling error (failure of MD to obtain
malignant cells from the cervix; failure to take samples from the squamo-columnar junction)
– Lab Error
• Note: testing for HPV not currently recommended
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The Evidence• No RCT’s- due to the widespread use of
this screening test
• Only Cohort and Case-control studies provide evidence for a reduction in the incidence of invasive disease
• Optimal frequency of screening is less known
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Cervical Cancer Screening Guidelines
AAFP: American Academy of Family Physicians ACOG: American College of Obstetricians and Gynecologists ACS: American Cancer Society AMA: American Medical Association CTFPHC:Canadian Task force on Preventive Health Care USPSTF: U.S. Preventive Services Task Force
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Canadian GuidelinesAddendum
• Consider screening more frequently in high risk women (due to the high FN rate and the variable rate of progression of disease)
• The largest group of women at risk of dying from cervical cancer are those who have never been screened before
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BACK TO THE CASE• Continue screening every 3 years until
the age of 69
• The Pap tests will eventually end....
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Principles of Cancer Screening
• Screening of asymptomatic individuals to detect early cancers which may be curable
• Use of diagnostic tests of high sensitivity• Diagnostic tests are suitable to the patient• Natural history of disease can be
changed by intervention• Proposed early treatment should be
beneficial and not harmful to the patient