Definitions Rationale Who is at risk Guidelines. Overarching recommendations

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1 Ana Maria Lopez, MD, MPH, FACP Professor of Medicine and Pathology Arizona Cancer Center University of Arizona Definitions Rationale Who is at risk Guidelines Breast Cancer Colorectal Cancer Prostate Cancer Overarching recommendations Ms. Janet Jones is a 35 yo woman who presents to your office with questions re: breast cancer risk since her sister (42 yo) was just diagnosed with breast cancer. Her mother had died at the age of 48 with metastatic breast cancer. Her grandmother had died at 52 of cancer that had spread everywhere. Ms. Janet Jones is a 35 yo woman who presents to your office with questions re: breast cancer risk since her sister (42 yo) was just diagnosed with breast cancer. Her mother had died at the age of 48 with metastatic breast cancer. Her grandmother had died at 50 of cancer all over her belly. Screening Test asymptomatic individuals to identify malignancy Earlier diagnosis greater likelihood of cure Later diagnosis cure less likely, treatment more resource intensive with greater cost

2 Lead time bias SBE CBE Mammogram MRI ACS Guidelines Annual mammography 40 yo+ CBE: <40 yo every 2-3 yrs, 40 yo+ preferably annual SBE: educate Greater than 50 yo yo Use of HRT Breast density Number of views taken Experience of radiologist Choice of follow-up evaluation Sensitivity: TP 1 time-71-96% Sensitivity decreased with younger age Greater FP in younger age group FN 10-20%

3 BRCA positive High risk (>25% lifetime risk) Post breast cancer diagnosis, to assess contralateral breast Ms. Janet Jones is a 35 yo woman who presents to your office with questions re: breast cancer risk since her sister (42 yo) was just diagnosed with breast cancer. Her mother had died at the age of 48 with metastatic breast cancer. Her grandmother had died at 50 of cancer all over her belly. Consider high risk evaluation with breast MRI and genetic counseling/testing for sister. Mr. Oliver Hutchinson is a 50 yo man who comes to your office accompanied by his wife who wants him to get all the tests he needs. She recently turned 50 and had a colonoscopy which he is not interested in pursuing. gfobt FIT sdna Flexible sigmoidoscopy DCBE Virtual Colonoscopy Colonoscopy The multistep model of colorectal carcinogenesis ( vogelogram ). (After Fearon and Vogelstein 1990).

4 Cancer detection FOBT: guaiac FIT (sdna) Endoscopy Flex-sig Colonoscopy DCBE CT colonography Average risk adults: start at 50yo Annual: gfobt, FIT (sdna unk) Every 5 years: flex sig, BE, CT colonography Every 10 years: colonoscopy h/o adenomatous polyps Personal hx of CRC FH: 1 st degree relative under 60 yo Inflammatory bowel disease Hereditary syndrome Mr. Oliver Hutchinson is a 50 yo man who comes to your office accompanied by his wife who wants him to get all the tests he needs. She recently turned 50 and had a colonoscopy which he is not interested in pursuing. Review screening options. Identify study acceptable to him. Mr. Arthur Andrews is 60 yo. He has a stable history of nocturia and comes to you for the blood test to prevent prostate cancer. Mr. Arthur Andrews is 60 yo. He has a stable history of nocturia and comes to you for the blood test to prevent prostate cancer.

5 Average risk, life expectancy +10 y (consider d/c at 75 yo), 50 yo +: PSA, DRE Improves prostate cancer related mortality No impact on all cause mortality Strong emphasis on shared decision making African American men Close relative dx d prior to 65 yo Discuss at 45 yo Close relative dx d prior to 65 yo Discuss at 40 yo Mr. Arthur Andrews is 60 yo. He has a stable history of nocturia and comes to you for the blood test to prevent prostate cancer. Shared decision making as review screening approaches. Mr. Arthur Andrews is 60 yo former heavy smoker. He has severe COPD (on steroids and O2) and CHF (EF 31%) with a stable history of nocturia. He comes to you for the blood test to prevent prostate cancer. Life expectancy <10 years. Review options with patient. Consider watchful waiting. Unknown 1848 smoking increases risk by about 25 per cent while being overweight by more than 7 kilos (15 lbs) can increase risk by as much as 60 per cent!

6 Be as lean as possible without becoming underweight. Be physically active for at least 30 minutes every day. Avoid sugary drinks, and limit consumption of high-calorie foods, especially those low in fiber and rich in fat or added sugar. Eat more of a variety of vegetables, fruits, whole grains, and legumes (such as beans). Limit consumption of red meats (including beef, pork, and lamb) and avoid processed meats. If you drink alcohol, limit daily intake to 2 drinks for men and 1 drink for women. Limit consumption of salty foods and food processed with salt (sodium). Don't use supplements to protect against cancer. It's best for mothers to breastfeed exclusively for up to 6 months. After treatment, cancer survivors should follow the recommendations for cancer prevention. Choose mostly plant foods. Limit red meat and avoid processed meat. Be physically active every day in any way for 30 minutes or more. Aim to be a healthy weight throughout life. Rates: lower than feasible or optimal Approaches: Improve awareness Increase health professional incentives Implement reminders in EHR Expand community programs and finance systems to increase access to care Having health insurance Having health care especially a stable relationship with a physician/health care professional Having physician recommend screening

7 Health care system needs to support screening applications if they are to be adopted

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