Prevention/Screening

Mammography

• Age 50-74 --> Mammogram q2yrs
  • (equivalent to 5 weeks of background radiation)
• Source: Cancer Care Ontario (based on Swedish Two-Country Trial - screen 414 over 7 years to prevent death)
• Screening ages 40-49 --> 2007 Meta analysis --> not effective.

 

• Ages 40 – 49 not routinely screening with mammography.

(Weak recommendation; moderate quality evidence)

• Ages 50-69 routinely screening with mammography every 2 to 3 years
  (Weak recommendation; moderate quality evidence)
• Ages 70 - 74 routinely screening with mammography every 2 to 3 years.
  (Weak recommendation; low quality evidence).

 

Magnetic Resonance Imaging

• not routinely screening with magnetic resonance imaging
  (Weak recommendation; no evidence)

 

Clinical Breast Exam

• We recommend not routinely performing clinical breast exam alone or in conjunction with mammography to screen for breast cancer.
  (Weak recommendation; low quality evidence).

 

Self Breast Exam

• We recommend not advising women to routinely practice breast self exam (D recommendation)
• Fair evidence no benefit, good evidence of harm (Increased physician visits, increased rates of benign biopsy)

 

• Any new breast lumps/masses must be investigated to rule out malignancy:
  • Ultrasound for women < 35yo (due to higher breast density)
  • Mammography if ≥ 35yo
  • Some sources have age cutoff of 30 (ESMO guidelines 2013)

Canadian guidelines for Colorectal Cancer (Cancer Care Ontario) - CMAJ

 

Moderate Risk
    Family Hx --> 1st degree relative diagnosed <60 OR two 1st degree relatives
    Start: 40y or 10 years before diagnosis (whichever earlier)
    - Colonoscopy q5y

High Risk
    FAP
            -  Flex sig/colonoscopy yearly starting teens until advised to have surgery
    HNPCC
            - Colonoscopy at age 20-25 q2y until age 40, then yearly after 40.
    IBD (Ulcerative Colitis or Crohn's Disease)
            - Colonoscopy q1-2y after max 8y of colitis
            - Multiple biopsies to r/o dysplasia even if no lesions found
            - No screening if only proctitis

PSA

• No routine screening!
• D - recommendation

• Evidence that PSA increases detection rate, but no evidence that reduces mortality (gold standard to evaluate screening).  It is generally used to monitor disease progress.
• Can offer to fit men 50-70yo with 10+yr life expectancy, but generally don't have to do.
• Not covered by OHIP
• Two studies:
  • PLCO (US) 
  • ERSPC (Large European Study)
    • NNS 781 over 13yrs. (twice needed to screen in twice time period)

Routine PAP

• Once sexually active and age 21-69 (if not sexually active, can wait)
  • PAP smear q3y

 

• Stop if >60yo and 3 paps normal.
• Very little mortality data, but shown that screening decreased cervical cancer by 60%.  Seems that NNT is >100,000.
• If HPV negative, risk of CIN 3+ after 6y is 0.27%

Gardasil

• Give 3 doses: now, in 2mo, and in 6mo.
• Covered by OHIP only for girls in Grade 8 (as of summer 2012)

DEXA

• At ≥65 Screen Everyone (males + females)
• 50-64 if risk factors:
  • Fragility fracture >40yo
  • Prolonged use of glucocorticoids (>3mo cumulative in previous year at dose of ≥7.5mg daily)
  • Use of other high risk medications (i.e. aromatase inhibitors or androgen deprivation therapy)
  • Parental hip fracture
  • Vertebral fracture or osteopenia identified on Xrays
  • Current Smoker
  • High Alcohol Intake (>2 drinks/day)
  • Low body weight (<60kg) or major weight loss (>10% of body weight since 25yr)
  • Rheumatoid Arthritis
  • Other disorders associated with osteoporosis
• <50yo if SEVERE risk factors such as:
  • Fragility Fracture
  • Prolongued glucocorticoids (>3mo cumulative in previous year at dose ≥7.5mg daily)
  • Hypogonadism or premature menopause (age < 45yr)
  • Malabsorption Syndrome
  • Primary hyperparathyroidism
  • Other disorders ass'd with rapid bone loss/fracture. 
• Screen q 1-3 years (usually 3)

 

Ca / Vitamin D

• Calcium: 1200mg (Concern over artery calcification if too much)
• Vitamin D:
  • Cancer Guideline: 1000
  • Osteoporosis Guideline: 800

Lipid Profile

• men 40-75
• Women 50-75
• Every 3-5 years
• Age to screen varies based on:
  • Smoking, Diabetes, HTN, Obesity
• Screen earlier if:
  • Rheumatic: SLE, RA, Psoriatic arthritis, Ank Spond, IBD
  • Chronic: COPD, CKD, HIV
  • Genetic: SE Asian, First Nations
  • Other: Abdominal Aneurism, Erectile Dysfunction.

Fasting Glucose

• ≥40, q3y

Framingham Risk Score

• Components:
  • Age
  • LDL-C
  • Total Cholesterol
  • HDL-C
  • Blood Pressure
  • Diabetes
  • Smoker
• Set lipid targets based on risk (see Lipids)
• Double risk if positive family hx (First degree relatives):
  • < 55 y for Men
  • < 65 y for Women
• Young individuals: Poorly represented.
  • Use Calculated Cardiovascular Age to motivate young people to achieve risk targets (exercise, diet, quit smoking).
• >75yo --> not well validated.  Studies underway as of 2014

 

Endometrial Ca

• An endometrial biopsy must be obtained to exclude hyperplasia or malignancy in all women over 40.