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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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
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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
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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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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
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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
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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)
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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
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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 ?
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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
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Do You Smoke Cigarettes?
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