Disclosures Cancer Screening 2018 New Recommendations, I have no conflicts of interest New Controversies Coleen Kivlahan MD, MSPH Executive Director of Primary Care at UCSF Health Professor, Family and Community Medicine Selected Controversies in Screening Principles of screening • Asymptomatic patients • Breast Cancer – High sensitivity, high true positive rate • Colorectal Cancer – High specificity, low false positive rate • Lung Cancer – Early detection reduces risk of death from • Prostate Cancer the cancer – Reasonably high prevalence of disease – Test results in minimal harm Page 1
USPSTF USPSTF Grades • Rigorous review of existing peer- reviewed evidence • Strength of the evidence on the benefits and harms reflected in ratings • No consideration of costs • ACA: Must cover services with A or B ratings Breast Cancer Screening ACS Cancer Cases and Death Rates • The most common cancer in women, second leading cause of cancer death • Screening mammography reduces breast cancer mortality • Risk of breast CA increases with age, median age 62 Page 2
Breast Cancer Deaths U.S. breast cancer screening guidelines: limited agreement Randomized Trials, all ages Stopping Organization Starting age Frequency Comments Age, years Deaths Averted 95% age Screening confidence United States 1,000 Women Over 10 Interval Screening for age Preventive Services Years 50 74 Biennially 40-49 = Grade C Task Force recommendation (USPSTF) 40 to 49 0.3 0 to 0.9 Annually, Continue screening 50 to 59 0.8 0.2 to 1.7 As then as long as good American Cancer appropriate 60 to 69 2.1 1.1 to 3.2 45 biennially health, life Society (ACS) based on life once age expectancy > 10 70 to 74 1.3 0 to 3.2 expectancy ≥ 55 years. 75+ Unknown -- American College As Consider cessation of Obstetricians appropriate 40 Annually of screening at age and Gynecologists based on life 50 to 69 1.3 0.6 to 0.2 75. (ACOG) expectancy False-Positive Results and Breast Harms Of Screening Biopsies/1000 women • 1 st mammogram at age 40, the 10-year Harms of One-Time Mammography Screening, cumulative risk of a false-positive biopsy result by age was higher (7.0%) for annual vs biennial (4.8%) Outcome 40-49 50-59 60-69 70-74 screening. False-positive 121 93 81 70 • CBE adds no mortality benefit to mammography mammogram (12%) (9%) (8%) (7%) and has a higher false-positive rate Breast 16 16 17 18 biopsies (1.6%) (1.6%) (1.7%) (1.8%) • False positives: Anxiety, biopsies, cost recommended • Radiation exposure: One breast cancer for 3000 Biopsies per 10 6 3 3 women screened annually for 10 years cancer diagnosed .JAMA 2015 Oct 20;314(15):1615-34. Benefits and Harms of Breast Cancer Screening: A Systematic Review. Myers ER 1 et al Page 3
Screening has led to large increase in State breast density legislation detection of ductal carcinoma in situ (DCIS) • Increased breast density IS Figure 2. SEER9 Age-adjusted incidence rate of breast cancer by stage (1973-2005) a risk factor for BC Screening era 100 • Must notify women with 90 Localized dense breasts 80 Incidence rate (per 100,000) 70 • There is decreased 60 In situ Rate sensitivity and increased Localized Rate 50 Regional Rate risk for BC with mamm Distant Rate 40 DCIS 30 • Insurance may not cover 20 supplemental screening 10 Metastatic 0 1975 1980 1985 1990 1995 2000 2005 Year of diagnosis Li CEBP 2005 Li CEBP 2005 Breast Cancer Screening What do you recommend to Maggie? a) Add ultrasound • Maggie is a 50 year old woman with no b) Add breast MRI family history of breast cancer. She has c) Mammogram alone been reading news articles about the � increased accuracy � of screening d) Add ultrasound and MRI ultrasound or MRI in women with dense breasts. • You perform a clinical breast examination, which is normal. Page 4
Newer Breast Technologies Digital mammography • Test of choice in asymptomatic women • Digital Mammography • Higher sensitivity(78% vs 51%), same • Digital Breast Tomosynthesis specificity(90%) in women < 50 years • Breast MRI old, dense breasts • Breast Ultrasound • Worse in women 65 and older – Sensitivity 53% versus 69% film Digital Breast Tomography/3D Mamm MRI Screening • Digital Breast Tomography (DBT) NOT a primary screening strategy – Highly sensitive breast imaging as a diagnostic tool in women with breast cancer – Specificity is variable – Useful in dense breasts – Expensive Yaffe Breast Cancer Research 2008 10:209 http://www.nydailynews.com/ Page 5
Impact For Clinical Practice Supplemental screening: better outcomes? MRI Ultrasound (US) Tomosynthesis • MRI may be useful in screening high risk (DBT) • • • women but mortality impact is not known Advantages Most sensitive Well-tolerated Similar cancer • • No radiation Relatively detection rate, inexpensive fewer false • MRI screening is not currently positives recommended for average risk women • Ultrasound adds little to mammography for Limitations • High false • High false • Not as sensitive positive rate positive rate as MRI screening • • Overdiagnosis (low PPV) Limited • • IV contrast Operator- evidence base • 3D mamm/BDT shows promise • Expensive dependent (newer) • Limited availability USPSTF Grade I: January 2017 Conclusion: Breast Cancer • 40-49 informed consent – Digital mamm is standard Lung Cancer Screening • 50-74 screen every 2 years • 75+ informed consent – only if life expectancy > 10 years • Don � t promote CBE/SBE Page 6
USPSTF 2013 Recommendation Mr. Nico is a 69 year old man with a 50 pack-year history of smoking and COPD. You have previously been unsuccessful in encouraging him to quit smoking. He comes in for a check-up, is worried about developing • Recommends annual screening for lung lung cancer and wants to know what test you think he should have. cancer What do you recommend? • Use low-dose CT in age 55-80 • With 30 pack year hx smoking a. Chest X ray b. Sputum cytology • And currently smoke or quit within past year c. Low Dose CT chest – Grade B recommendation d. None of these tests – Published December, 2013 Feb 2018 CHEST guidelines Low Dose Spiral Computed Tomography • Supports USPSTF recs • Scans lung in < 20 seconds (single breath) • Low-dose CT screening should NOT be • No IV contrast routinely performed for • More radiation exposure than CXR but –Smokers who do not meet the smoking less than conventional CT and age criteria –Comorbidities that adversely influence • Can detect much smaller lesions than ability to tolerate the evaluation of chest X-ray findings, or tolerate treatment of an early stage lung cancer, or substantially limit life expectancy Screening for Lung Cancer: CHEST Guideline and Expert Panel Report. Peter J. Mazzone, MD, MPH. CHEST Feb 2018, Am College of Chest Physicians Page 7
NCI Risk-based Screening The National Lung Screening Trial (NLST) • 50,000 people randomized to CT or CXR • Individualized risk-based screening may be more effective at preventing lung cancer deaths than current USPSTF screening - Current or former heavy smokers: ≥ 30 criteria. pack-years • Lung Cancer Risk Assessment Tool would include high-risk - Ages 55 to 74 moderate smokers with a history of 20 to 29 pack-years who are currently ineligible for screening - Annual CT scans x 3; 6.5 years follow- • Smoking-cessation counseling remains a high priority for clinical up attention in discussions with current smokers, who should be informed of their continuing risk of lung cancer; screening should • 20% reduction in lung cancer death with not be viewed as an alternative to smoking cessation screening CTs LDCT Screening Harms Medicare Coverage Decision • Annual screening age 55-77, • False positives asymptomatic, at least 30 pack year – At least 1 positive test in 40% history and currently smoking or quit CTs within past 15 years • Possible overdiagnosis of early • Written order for lung cancer cancers screening, shared decision making • Radiation exposure visit by physician or APN/PA • Incidental findings CMS, February, 2015 Page 8
Primary Prevention Of Implications for Practice Lung Cancer • Smoking cessation • Adherence to guidelines – 55-79 years, 30+ pack years • Watch for better risk-based screening soon • Use experienced centers to ensure quality and effectiveness of CT Incidence and Mortality are Dropping Colorectal Cancer Page 9
Joint Guideline: ACS, ACR, What do you most commonly recommend for Multi-Society Task Force colorectal cancer screening? • FOBT annually • Fecal immunochemical test annually a. Fecal occult blood test (FOBT) b. Fecal immunochemical Test (FIT) • Flexible sigmoidoscopy every 5 years c. Sigmoidoscopy • DCBE every 5 years d. Colonoscopy • CT colonography every 5 years e. Virtual Colonoscopy f. Fecal DNA • Colonoscopy every 10 years • Stool DNA testing (interval uncertain) Levin, Gastroenterology, 2008 All CRC Guidelines • Discuss the menu of options with patients • Offer a test that is effective at both cancer prevention AND early detection • CRC prevention should be the primary goal of screening Page 10
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