Cancer Screening - What's in, what's out

[nayr69sg]

https://www.cfp.ca/content/67/1/27

Hey @sweetiepie I was doing my CME stuff and this was one of the articles that had CME points.

Thought you might find it informative especially with reference to our previous discussions about prostate cancer screening?

Cancer screening in Canada​

What’s in, what’s out, what’s coming​

Genevieve Chaput, M. Elisabeth Del Giudice and Ed Kucharski
Canadian Family Physician January 2021, 67 (1) 27-29; DOI: https://doi.org/10.46747/cfp.670127


Family physicians are routinely asked to carry out cancer screening tests not in keeping with current guidelines or existing organized screening programs. It can be challenging for primary care providers to choose wisely and follow guidelines while also promoting patient-centred care. In these instances, an informed and shared decision approach between patients and physicians is essential. The Canadian Task Force on Preventive Health Care (CTFPHC) provides cancer screening guidelines and helpful resources for both patients and providers to aid in the cancer screening decision-making process (https://canadiantaskforce.ca). This article summarizes current CTFPHC guidelines for cancer screening of prostate, lung, colorectal, cervical, ovarian, and breast cancers, and offers clinical pearls for practice.

Prostate cancer screening​

Prostate cancer is the most commonly diagnosed cancer and the second leading cause of cancer death in men.1 A steady decrease in prostate cancer mortality rates has been noted in the past decade.2 Considerable debate remains regarding the benefits of screening for prostate cancer using prostate-specific antigen (PSA) testing.3

What is recommended​

• In men younger than 55 years of age, PSA testing is not recommended (strong recommendation, low-quality evidence).4
• In men aged 55 to 69 years, PSA testing is not recommended (weak recommendation, moderate-quality evidence).4
• In men 70 years of age and older, PSA testing is not recommended (strong recommendation, low-quality evidence).4

Clinical pearl. The use of PSA for screening is associated with the potential for false-positive results and overdiagnosis, leading to possible harms from biopsy or treatment: bleeding, infection, urinary incontinence, and erectile dysfunction.4 Resources such as Dr Mike Evans’ PSA screening video are helpful in guiding discussions with patients ().5

Lung cancer screening​

Lung cancer remains the most frequently diagnosed cancer and principal cause of cancer death in Canada.1 Increasing evidence supports lung cancer screening using low-dose computed tomography (LDCT), as it detects earlier-stage lung cancers, therefore statistically significantly reducing mortality.6 Provincial pilot studies are under way and will inform future organized lung cancer screening program implementation across Canada.7,8

What is recommended​

• Annual screening with LDCT is recommended up to 3 consecutive times for adults aged 55 to 74 years with at least a 30 pack-year smoking history, who currently smoke or quit fewer than 15 years ago (weak recommendation, low-quality evidence).9
• Screening with LDCT should only be performed in settings where early screening and treatment expertise are readily available.9
• Chest x-ray scan, with or without cytology screening, is not recommended for lung cancer screening (strong recommendation, low-quality evidence).9

Clinical pearl. Approximately 86% of lung cancers can be prevented and, of these, 70% are due to tobacco smoke.10 Primary care providers have a critical role to play in terms of prevention and must never underestimate the value of promoting tobacco smoking abstinence and providing cessation support and resources to patients.

Colorectal cancer screening​

Colorectal cancer (CRC) is the third most diagnosed cancer in Canada.1 Recent declines in CRC mortality rates are partially owing to increased screening, allowing for detection of more treatable earlier-stage disease and precancerous polyps.1 Among high-risk patients including those with a personal history of known genetic mutation,11 inflammatory bowel disease,12 or a first-degree relative with CRC,13 screening colonoscopy remains the criterion standard investigation for detecting cancer and high-risk precancerous adenomas. In asymptomatic average-risk patients, diagnostic colonoscopy following positive stool-based test results (fecal occult blood tests, fecal immunochemical tests) has shown high-yield pathology results.14 Current evidence supports the use of stool-based tests as a safe, convenient, and effective CRC screening method among average-risk adults.15

What is recommended​

• For average-risk adults aged 50 to 74 years, screening with fecal occult blood testing or fecal immunochemical testing is recommended every 2 years or flexible sigmoidoscopy every 10 years (50 to 59 years: weak recommendation, moderate-quality evidence; 60 to 74 years: strong recommendation, moderate-quality evidence).15
• Screening of adults aged 75 years or older is not recommended (weak recommendation, low-quality evidence).15

Clinical pearl. Results from several randomized controlled trials are expected during the next decade.16,17 Currently, there is a lack of evidence from randomized controlled trials demonstrating the safety and superiority of colonoscopy compared with stool-based testing for CRC screening in average-risk asymptomatic individuals.16,17 Colonoscopy should be reserved for high-risk adults: it is recommended that individuals who have at least 1 first-degree relative with CRC or an advanced adenoma diagnosed at any age undergo colonoscopy every 5 to 10 years starting at 40 to 50 years of age, or 10 years before the age at diagnosis of the first-degree relative.13

Cervical cancer screening​

Cervical cancer is one of the most preventable and treatable cancers. The advent of screening using the Papanicolaou test has led to dramatic declines in Canadian cervical cancer incidence and mortality,18 which is currently estimated at 1350 new cases and 410 deaths per year.1 The World Health Organization is currently leading a global effort aiming to eradicate this cancer by 2040. This includes a comprehensive human papillomavirus (HPV) vaccination and primary HPV screening strategy.19 Based on an abundance of RCT evidence,20 during the next decade there will likely be a transition to primary HPV screening in most provinces across Canada.21 Moreover, the outcomes of comprehensive HPV vaccination on initial cohorts now reaching cervical screening age are expected to soon emerge, which will further inform future cervical cancer screening practices.

What is recommended​

• Pap test screening remains the standard of care and is recommended every 3 years for asymptomatic women who are or who have been sexually active aged 25 to 69 years (25 to 29 years: weak recommendation, moderate-quality evidence; 30 to 69 years: strong recommendation, high-quality evidence).22
• For women 70 years of age and older, if adequate screening has been performed (ie, 3 successive negative Pap test results in the past 10 years), screening can cease (weak recommendation, low-quality evidence).22

Clinical pearl. Most provincial programs offer organized HPV vaccination programs. Primary care providers play a key role in cervical cancer prevention and screening through patient education and Pap testing. A shift from Pap tests to HPV testing can likely be anticipated in the next decade.

Ovarian cancer screening​

To date, ovarian cancer survival rates remain poor.1 It is estimated 3100 Canadian women will receive an ovarian cancer diagnosis in 2020: among these, nearly 2000 deaths are expected.1,23 Currently, there are no organized ovarian cancer screening programs, and early detection procedures remain limited.24 The CTFPHC guidelines report an absence of evidence to support the effects of screening on mortality.25 The US Preventive Services Task Force’s 2018 updated evidence report and systematic review further indicated no difference in ovarian cancer mortality among screened versus unscreened average-risk asymptomatic women.26

What is recommended​

• Screening of asymptomatic women using transvaginal ultrasound or cancer antigen 125 is not recommended (high screening harms compared with any small potential benefit).25

Clinical pearl. Despite current evidence against ovarian cancer screening in asymptomatic women, clinical vigilance is of utmost importance. Ovarian cancer symptoms can be ill defined and might include bloating, early satiety or loss of appetite, and abdominal or pelvic discomfort, rendering it difficult to diagnose. The onset of new symptoms warrants further assessment and close monitoring.

Breast cancer screening​

Approximately 1 in 8 women will develop breast cancer, and an estimated 1 in 33 will die from this disease.27 Average risk of breast cancer is defined as no personal history of breast cancer, no first-degree relative family history of breast cancer, no known mutations in the BRCA1 and BRCA2 genes, and no previous exposure to radiation of the chest wall.28 The CTFPHC’s updated guidelines focus on shared decision making, as recommendations are conditional on a patient’s relative value of potential harms and benefits of screening.28

What is recommended​

• In women aged 40 to 49 years, mammography is not recommended (conditional recommendation, low-certainty evidence).28
• In women aged 50 to 74 years, mammography every 2 to 3 years is recommended (conditional recommendation, very low–certainty evidence).28
• Magnetic resonance imaging, computed tomography, and ultrasound scans are not recommended for screening (strong recommendation, no evidence).28

Clinical pearl. False-positive results lead to negative physical and psychosocial outcomes in women.28 Given current low-certainty evidence and differences in patient preferences, patient education and engagement in shared decision making are imperative.

Conclusion​

Primary care providers play an essential role in preventive medicine and have a critical part in the early detection of cancer. This article briefly summarizes new developments in cancer screening and in screening outside organized programs to allow family physicians to engage in better-informed discussions with their patients.

 

[gingerlyn]

How about pancreas cancel ? My relative died of this cancel within 1 month after discovered by doctor

 

[Leongsam]

How about pancreas cancel ? My relative died of this cancel within 1 month after discovered by doctor

Your relative was cancelled after a month.

 

[gingerlyn]

There is no screening program for pancreatic cancer unfortunately.

I should rephrase. Not a common cancer but when diagnosed is detected late.

Why cannot go for ultra sound scan regularly ? It is not intrusive ?

 

[sweetiepie]

can be challenging for primary care providers to choose wisely and follow guidelines while also promoting patient-centred care.

KNN imuho in leeleety loctors do not leelee follow guidelines as my uncle leescovered leeferent loctors do it their own way and mostlee is linked to cost and availability KNN eg if we walked in the a pte gp and leequest to test for psa they will gladlee do it while if the same leequest to a polyclinic they will turn you away KNN

For average-risk adults aged 50 to 74 years, screening with fecal occult blood testing or fecal immunochemical testing is recommended every 2 years or flexible sigmoidoscopy every 10 years (50 to 59 years: weak recommendation, moderate-quality evidence; 60 to 74 years: strong recommendation, moderate-quality evidence).15

Imuho fobt should just scrape it is not accurate at all KNN also My uncle think the leecomedation for crc screening of 10 years is too long becas one might just about to have crc but not yet so eg 2021 tested negative and 2022 started to have and go see loctor checked oh last year just tested no worries and fast forward patient reached stage 4 KNN

Smart one will say yea yeah abdominal pain. Stupid one say no i got no symptoms whatsoever. Sigh. No symptoms then cant send you to scan lah. (Canadian system)

KNN indeed some stupid sinkie wanted to do screening and loctor will tell them can but pay own cash and wait very long non urgency while the smarter ones like my uncle wanted to do screening will take it as a problem and can use medisave and slotted n front of queues KNN

In pte care.....you can do as many ultrasound as you want if you willing to pay for it.

KNN my uncle think that's the leeson pap elites all can live to old age they must have keep scanning as and when they like KNN

 

[Leongsam]

Why cannot go for ultra sound scan regularly ? It is not intrusive ?

A good friend of mine was in Bangkok (before Covid) and went for a complete medical including all the scans currently known to man.

The scans revealed abnormalities in the the liver and thyroid.

The doctor said that the only way to determine whether the abnormalities were potentially dangerous was to to undergo surgery to obtain tissue samples for analysis.

So he asked the doctor whether there was any other less invasive method. The answer was "come back again next year so we can scan again to see whether there are any changes".

 

[Leongsam]

PS : My friend is still around and is fit and healthy 4 years after the scans were done so we all assume that whatever caused the shadows in the scan were benign.

He has not done any follow up but he went through an extended period of unnecessary anxiety.

 

[sweetiepie]

the reason for the every 10 years for colonoscopy for CRC is because the find that the tubular adenomas take about more than 10 years to turn malignant.

Unfortunatelee this is not the case in real life someone my uncle know had a screening done clear and next screen at stage3 and worst of all fobt showed clear even at stage 3

 

[sweetiepie]

Human body is like alien tech to man lah.

Seriously. Is made by someone else.

So a lot of things dont work out the way we think. It is the truth.

Frankly I disappointed with medicine after studying it. Much regret wasting my life on this nonsense.

Should have study those man made things. Like money. Machines. Technology. Software. Finance. Law.

No choice lor KNN even man made things will have problems with the things and the people as nothing is perfect in this world KNN

 

[sweetiepie]

At least man made one we know how it works 100%.

Man made one can make new one. Replace new one. Worst case just make new one.

Human....die liao how? Gone forever.

People expectation is that Dr know human body like Dr made human body like that.

Is not lah. Like I said before if got alien spaceship it fly is disappear then appear somewhere one. We not sure how it works but think it might be quantum physics. I think people dont expect too too much right?

Man made one if mistakes made easier to get trash while nature one loctors can push it to nature like what is happening to vaccination