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Transcript Breast Cancer
Cancer Screening 101:
What Do I Recommend To My Patients?
Kenneth R. Kunz, M.D., Ph.D.
Medical Oncology
Pharmaceutical Sciences
[email protected]
The Death of Achilles; Peter Paul Rubens, 1635
Conflict of Interest
I have no involvement with industry and cannot
identify any conflict of interest
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Cancer Screening 101
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Can We Eliminate Cancer?
There is a belief that if we just managed
better we could eliminate cancer
In 1971 Nixon declared a “War on Cancer”
Trillions of dollars have been spent on research
The result is that cancer has now risen to be the number
one cause of death in North America
On December 23, 1971, President Richard Nixon signed the
National Cancer Act and declared "war on cancer."
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Cancer Screening
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The Ebers Papyrus (1550 BC) discusses the management of cancer
3,200-Year-Old Skeleton is Oldest
Known Case of Human Cancer
Cancer has long been considered a modern disease
Current, modern risks absent in ancient populations
British archaeologists in Nile River Valley
3,200-yr-old skeleton of a young man riddled with cancer
Skull radiograph featuring myeloma
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72 million–year-old Gorgosaurus
died from complications of bone cancer
There will never be a future without
cancer because cancer is a natural
consequence of living
17-Jul-15
breast cancer
National Geographic News. Nov. 24, 2003
5
What is Cancer?
CT scan: spread to liver
Appearance at autopsy
The cells making up normal tissue are well organized because they have a
specific function. Cancer occurs when these cells undergo mutations that
transform them into bizarre looking shapes that show an invasive, infiltrative
and destructive growth pattern, spreading by erosion and digestion through
tissue planes into adjacent organs, along nerve sheaths, and penetrating
lymphatic channels and blood vessels to cause widespread, distant
metastases and death.
Normal pancreas cells
Pancreatic Cancer
Cancer cells in blood vessels
They get there on purpose
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Statistics Canada 2009
Cancer 30% of deaths
Heart attack 21%
Stroke 6%
Population 34 million
Statistics Canada 2014
191,300 new cases of cancer and 76,600 deaths
Every hour of every day 22 Canadians diagnosed with cancer and nine
people die of cancer (500 per day, 200 deaths)
About 1/3rd of all deaths in Canada are due to cancer
More men than women die of cancer: 52% 48%
The average Canadian is at high risk for cancer
Alive with
Pleasure
Cancer
is increasing
by 1.5% per year
Population is growing and aging
Risk increases with age and related exposures
Smoking, overweight and inactivity are the chief factors
Related to adverse childhood events (Vincent Felidy)
Susceptibility
modified
risk factors
such as family history
1 week groceries
= $1.23by individual
1 week groceries
= $341.98
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Big Corporations Promote Chronic Disease: by
providing an over-abundance of inexpensive,
good tasting, super-sized, calorie
dense, preservative rich processed food, which
is widely available with little or no physical
effort.
$=
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Prostate Cancer
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Canadian Cancer Statistics 2014
Type
New Cases
Deaths
Mortality Rate
Lung
26,100
20,500
79%
Breast
24,600
5,100
21%
Colorectal
24,400
9,300
38%
Prostate
23,600
4,000
17%
Bladder
8,000
2,200
28%
Lymphoma
8,000
2,600
33%
Cervix (20th)
1,450
380
26%
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Cancer Screening 101
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Lung Cancer Screening in Canada
Seventy Jumbo Jets
NOT RECOMMENDED: for asymptomatic individuals
Canadian Task Force on Preventive Health Care (2003)
1. Nconcluded
Engl J Med
2013; 368:1980-1991.
May 23,CT2013
“insufficient
evidence to recommend
scan,
2. Nradiography,
Engl J Medor
2013;
369:245-254.
July 18th,
2013
sputum
cytology screening
for lung
cancer”
In 2013 the US National Lung Screening Trial showed a 20%
reduction in lung ca. mortality in 55-74 yrs. with 30
pack/years screened within 15 years quitting
In 2014 the USPSTF recommends annual screening for lung
cancer with low-dose CT for ages 55 to 80 yrs. who have a
30 pack-year smoking history and currently smoke or have
quit within the past 15 years
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Dr. Jennifer Telford, Gastroenterologist
St. Paul’s Hospital
Colorectal Cancer Screening
Despite excellent screening and preventative strategies
colorectal cancer remains a major public health problem
Early detection decreases the incidence and mortality rate
with less need for surgery, colostomy and chemo/XRT
Screening is cost effective
In 2013 British Columbia introduced a high quality,
population-based screening program
Target population: asymptomatic BC residents age 50 to
74 years
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Average Risk Colorectal Cancer Screening
Fecal immunochemical test (FIT) every two years
Patient receives requisition from primary care provider
Picks up FIT from lab, completes at home, returns to lab
Results Mailed to GP, BCCA
Normal result: BCCA recalls patient for rescreening in two
years
Abnormal test: patient assessed for colonoscopy
Primary Care Providers play the key role
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Higher Than Average Risk CRC Screening:
Straight to Colonoscopy
Who is high risk?
First degree relative diagnosed with colon cancer under
the age of 60
2 or more first degree relatives with colon cancer
diagnosed at any age
A personal history of adenomas
Note on adenomatous polyps
Prevalence of polyps is 25% by age 50, and 50% by age 70
Adenomas > 1 cm have 15% chance of progression to cancer over a 10yr period
Adenomas > 2 cm have a 40% likelihood of malignant transformation
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Colorectal Cancer Screening
High Risk Screening interval:
Colonoscopy every five years for patients with family history of
colon cancer;
Colonoscopy in five years after a patient has low risk adenoma(s)
identified;
Colonoscopy in three years after a patient has high risk
adenoma(s) identified
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Colonoscopy: sequence of events for high risk
patients/or positive FIT
Pathway is facilitated for patients through HA coordinators
working with centralized BC Cancer Agency colon screening
registry
BCCA facilitates referral to HA patient coordinator
Patient is educated, scheduled for, and undergoes procedure
Colonoscopist provides report to GP, coordinator, BCCA
Pathologist reviews specimen and sends report to GP, coordinator,
BCCA
BCCA provides next recommended screening interval information
to GP
Coordinator provides results to patient by 14 days
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Colonoscopy Sequence of Events (con’t)
Normal result/no adenomas: BCCA recalls patient for
FIT in 10 years
Patient with family history is recalled for colonoscopy
in five years by BCCA
Low risk adenoma repeat colonoscopy in 5 years
High risk adenoma repeat colonoscopy in 3 years
Cancer or IBD detected, patient taken out of program
Colonoscopist facilitates further management with GP
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Fecal Immunochemical Test (FIT)
Antibodies directed against human globin
Approved by Health Canada in 2008, many other countries
Automated test reading, quantitative results
Superior to gFOBT –which is now considered obsolete
Higher sensitivity for CRC (80% vs. 40%)
Higher sensitivity for advanced adenomas (40% vs. 20%)
More specific for colon blood
Unaffected by diet or medications
Improved compliance---one stool specimen required
Disadvantages: more expensive, sample can degrade
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FIT Not Recommended for:
Screening in individuals less than 50 or over 74 yrs.
Individuals in poor health who cannot undergo
colonoscopy
Individuals up to date with CRC screening
Individuals already in a colonoscopy surveillance program
Individuals with GI symptoms or IBD
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Why a CRC Screening Program?
Ad hoc or opportunistic screening has had no significant
impact on incidence or mortality of CRC over last 20 yrs.
Inconsistent follow-up & colonoscopy, pathology, etc.
Final points:
There are major risks associated with screening programs
Colonoscopy is an operator dependant, invasive and costly
procedure: perforation, bleeding, missed lesions
There are major benefits associated with screening
programs—reduced mortality
Family Physicians play a key role in reducing CRC rates
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Breast Cancer Screening Program of BC
The Natural History of Breast Cancer
. There has been considerable back and forth in the literature
n= 1,372
regarding
the
potential harms and benefits of breast cancer
.
screening/mammography
.
100
Survival %
80
60
40
20
Seven different studies
Mammography
.
reduces mortality: Lessons From the Mammography
Wars. N Engl J Med 2010;363:1076-79
.
. .
Mammography
not reduce mortality: 25 yr. follow-up for
. . does
. .
breast
and mortality of the Canadian National Breast
1
2
3
4 cancer
5
6 incidence
7
8
9
10
Years from alleged onset
Screening
Study: randomized screening trial. BMJ 2014;348:g366 (11
February 2014)
What are the current recommendations in BC?
Screening is strongly recommended
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Dr. Christine Wilson, Medical Director, BCCA Screening Mammography Program
Breast Cancer Screening: Quick Facts
Breast cancer is the most common type of cancer
diagnosed in Canadian women
BC has one of the lowest incidence rates and the second
lowest mortality rate of breast cancer in the country
In 2014 an est. 3,600 women will be diagnosed with
breast cancer in BC, and 570 will die from the disease
Over 80 % of new breast cancers diagnosed each year in
BC are in women age 50 or older
Mammograms find cancers in earlier stages– when there
are more treatment options and better chance for cure
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Breast Cancer Screening: Quick Facts
281,715 screening mammograms were performed in BC in
2012, and 1,264 breast cancers were reported (4.5 per 1,000
exams)
“Research has shown a 25% reduction in deaths from breast
cancer among women who are screened through the
Screening Mammography Program of BC”
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February 4, 2014: Revised Breast Cancer
Screening Recommendations in BC
New recommendation for women 40-74 years old with FHx
of breast cancer in a first degree relative (mother, sister or
daughter) to receive annual screening
More than twice as likely to develop breast cancer
Women ages 40 to 49 will continue to have access to
screening every two years without a doctor’s referral
Encouraged to make an informed choice by speaking to their
health provider about benefits and limitations of screening
Women ages 50 to 74 should be screened every two years
This age group benefits most from routine screening.
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Other New Policy Recommendations
Women age 75 and older continue to have access to breast
screening without a doctor’s referral
Encouraged to make an informed choice by speaking to their
health provider about the benefits/limitations in context of
their personal health
Women age 40 and younger with a personal high risk of
developing breast cancer will require a doctor’s referral
Provided they not have breast implants or indication for
diagnostic mammogram
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Other New Policy Recommendations
Routine self-breast examinations as only screening method
not recommended for women at average risk
Routine clinical breast exam:
Insufficient evidence to recommend in the absence of
symptoms alone or in conjunction with mammography
Routine breast MRI screening of women at average risk is
not recommended
All women should be familiar with their breast texture and
appearance and bring any concerns to their doctor
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Limitations of Breast Cancer Screening
Mammograms are not perfect
Age or breast density can make cancers more or less difficult
to see
Mammography does not detect all cancers.
Mammograms find 4 in 5 cancers – some cancers are often
too small or in an area that is difficult to view
Mammograms may lead to additional testing
On average, 8% of women screened will require additional
testing. Of the women recalled only 0.4% will result in a
cancer diagnosis
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Screening for Prostate Cancer
NOT RECOMMENDED
Many men are harmed as a result of prostate cancer
screening and few, if any, benefit
Do not screen for prostate cancer by either PSA or
rectal examination
Even in asymptomatic high risk individuals
Screening finds cancer, but there is currently
inadequate evidence that doing so extends life, while it
exposes men to high risk of danger and side effects
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Marette Lee ‐ Gynecologic Oncology, November 2, 2013
Cervical Cancer Screening Update
Normal pap test
Approximately 200 new cases per year in BC
20% of women have had inadequate screening
Poorly screened women, more advanced disease, high MR
10% of eligible women have NEVER had a Pap smear
Some populations are screened less well and have higher
incidences of cervical cancer
Cervical cancer is 4‐6 times higher in First Nations women
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Current Screening Recommendations
Screening initiation
Age 21 or 3 years after sexual activity
Negative or benign
Q12 months x 3 negative, then Q24mo
Over 69
Stop if 3 normal in last decade
Pregnant
Screen in early pregnancy
HIV positive, immunosuppression
Q6 months x 2, then yearly
Previous CIN 2/3
Annually
Post hysterectomy (total)
Stop if prior normal and benign
Continue yearly X 3 if history of
dysplasia
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How Can Providers Fight Cervical Cancer ?
Identify eligible women for screening
Obtain high quality smears
Make appropriate referrals for abnormal results
Encourage smoking cessation
Encourage and provide HPV vaccination – up to 45y
YES!!
Offer to women who have had abnormal Paps, dysplasia
Bivalent vaccine available for free to <26yo
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Cancer Screening 101
Questions?
“Your cells take their signals from your beliefs”
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What Kind of Food do You Eat? How Much
Food Do You Eat?
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Do You Get Enough Exercise?
Arm Chair Suicide
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Exercise Prevents Cancer
Cancer Screening 101
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Do You Smoke Cigarettes?
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