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Cancer screenings: Who should be screened and what cancers can be detected?

March 26, 2018 | by CTCA

Physicians performing a cancer screening
Certain lifestyle habits and hereditary traits are linked to a number of cancers. Screening for various cancer types based on these factors may help patients determine their level of risk.

Breast self-exams, Pap smears, PSA screenings, genetic tests, colonoscopies—everywhere you turn, it seems, new recommendations are coming out about screening tests for various cancers. The information overload and sometimes-contradicting guidelines have many people confused: Should I get screened? If so, why, when and how often? The answers aren’t simple, or always black and white, but knowing which screenings are recommended for which cancers, and understanding your risks, is the first step in making sense of the confusion—and arming yourself with information you need to know about catching cancer early, when more options are more likely available to treat it, or prevent it altogether.

Given all the talk about cancer prevention these days, it may surprise you to know that screening tests have been developed for some but not all cancers, and a variety of considerations must be weighed by both doctor and patient when determining whether screening for a particular cancer type is warranted. Risk factors such as lifestyle habits, family history, comorbidities (other serious medical conditions, such as diabetes or heart disease) and environmental exposures all play pivotal roles in the decision-making process.

Cancer screenings are of increasing importance, especially as cancer diagnoses continue to rise. The U.S. Centers for Disease Control and Prevention (CDC) estimates that between 2010 and 2020, 24 percent more new cancer cases will be diagnosed in men (rising to 1 million a year) and 21 percent more new cases will be diagnosed in women (rising to more than 900,000 a year). At the same time, though, National Cancer Institute figures show that survival rates are at an all-time high—with nearly 14.5 million survivors living in the United States in 2014. That number is projected to reach 19 million by 2024. Cancer-related deaths also continue to drop steadily, falling 26 percent between 1991 and 2015. Many experts attribute the improved outcomes to treatment advances, prevention awareness efforts—and screenings designed to detect cancer in the early stages, when interventions tend to have the most impact.  

So which cancers should you be screened for, and when? It depends. Below is your guide to the three R’s of cancer screenings—risk factors, recommendations and rationale—by cancer type. We’ve compiled a list based on the recommendations of the leading cancer organizations—the American Cancer Society (ACS), the U.S. Preventive Services Task Force (USPSTF), the American College of Obstetricians and Gynecologists (ACOG) and the Society of Gynecologic Oncology (SGO).

Breast cancer

Risk factors: When it comes to breast cancer, women are typically categorized as high-, moderate- or low-risk (the last category representing most women).

  • You are considered high risk if you have:
    • A family history of breast and/or ovarian cancer with two or more close relatives on the same side of your family, especially when diagnosed before age 50
    • Any of the following inherited genetic mutations: BRCA1, BRCA2, CDH1, PALB2, PTEN or Tp53
    • Breast biopsy showing atypical cells, lobular carcinoma in situ or atypical lobular hyperplasia.
  • You are considered moderate risk if you have:
    • Dense breasts
    • A family history of breast cancer in distantly related relatives, especially if diagnosed in their 50s
  • You are considered average risk if you have both:
    • Good health
    • No family history of breast cancer

Recommendations: The leading cancer organizations differ on screening guidelines.

  • The USPSTF recommends that average-risk women under age 50 make individual decisions, and that women between 50 and 74 years old get a mammogram every other year. Those who have a first-degree relative with breast cancer may benefit from annual mammograms starting in their 40s.
  • The ACS recommends yearly mammograms beginning at age 45 through age 54. At 55, the ACS recommends the tests every other year, though women may choose to have them annually. Women considered high risk should get an MRI and a mammogram every year.
  • The ACOG recommends a mammogram yearly or every other year for women considered average risk, beginning at age 40 through age 75. For women who have the BRCA1 or BRCA 2 mutation, or who have one or more family members with the mutation, ACOG recommends twice yearly clinical breast exams, annual mammograms, annual breast MRIs, and regular breast self-exams.

Rationale: The ACS now recommends against breast exams, either performed routinely by a doctor or as a self-exam, urging women to know how their breasts normally look and feel and to report any breast changes to their health care provider. But many experts encourage women to perform breast self-exams frequently enough to be able to detect changes.

Check yourself enough so you know your normal texture and contours and can notice something out of the ordinary. There’s no longer the need for a ritual of self-exam, but a self-awareness of what you’re normal is. ” - Steven Standiford, MD, FACS - Surgical Oncologist at our hospital in Philadelphia

For healthy women with no family history of breast cancer, Dr. Standiford recommends beginning annual mammograms between ages 40 and 45 and continuing until age 70, then getting the tests every other year. He also urges women to get a 3D mammogram whenever possible because it provides a clearer picture, especially of dense breasts.

Dr. Standiford only recommends MRI screening for “very high-risk women” who carry inherited gene mutations, such as BRCA1, BRCA2 or Li–Fraumeni Syndrome. In those cases, he recommends both an annual mammogram and MRI, spaced six months apart. Women of Ashkenazi Jewish heritage who have no family history of breast cancer and are not carriers of a BRCA mutation should follow the same screening guidelines for women of average risk. He strongly recommends, however, that these women undergo genetic testing since Ashkenazi Jewish women are at an increased risk of having a BRCA mutation.

The most important recommendation, he says, is if a woman has a family history of breast cancer, she should have her first mammogram 10 years before the youngest age at which breast cancer was diagnosed in her family.

“If Mom had breast cancer at 40, daughter should start at 30 and then continue annually after that,” he says. “Keep getting mammograms annually until 70, and then stretch it out. If the breast cancer was in a second-degree relative, it’s not as significant, but if there are multiple relatives in one generation, I’d tend to screen the patient more often.” 

Gastrointestinal (GI) cancers

GI cancers affect the tissue and organs in the digestive system, which starts at the mouth and ends at the anus. Guidelines on screenings and risk factors have been developed for several GI cancers: colorectal, esophageal, liver, and pancreatic.

Colorectal cancer

Risk factors: Your risk of developing colorectal cancer increases with:

  • Age (more common in patients 50 and older)
  • Obesity and type II diabetes
  • Sedentary lifestyles
  • Moderate to heavy alcohol use
  • Personal history of colorectal polyps or family history of colorectal cancer
  • African American or Ashkenazi Jewish heritage
  • History of inflammatory bowel disease (IBS), colitis or Crohn’s disease
  • Lynch syndrome or other inherited gene mutations

Recommendations: Guidelines vary according to risk:

  • For those considered average risk—patients with good health and no family history of the disease—the ACS recommends colonoscopy screening beginning at 50 and repeated tests every 10 years if no polyps are found.
  • For those with a family history of colorectal cancer, the ACS recommends getting your first colonoscopy at age 40 or 10 years before the youngest case in the immediate family, and then repeat colonoscopies every five years.
  • If you have Lynch syndrome, you’re considered high risk and the ACS recommends you have your first colonoscopy between ages 20 and 25, or 10 years before the youngest case in the immediate family, and then every one to two years.
  • For those with IBS, ulcerative colitis or Crohn’s disease, also in the high-risk category, the ACS says the risk of cancer becomes significant “eight years after the onset of pancolitis (involvement of entire large intestine), or 12-15 years after the onset of left-sided colitis.” Colonoscopies should be performed on these patients every one to two years.

Rationale: Colorectal cancer—cancer of the colon and/or rectum—is the third most commonly diagnosed cancer in the United States, but in many instances, colorectal cancer may be prevented with regular screenings. “Colonoscopy is the gold standard for screening, followed by Cologuard® (an FDA-approved stool sample kit) or CT colonography,” says Pankaj Vashi, MD, Chair of the Department of Medicine at Cancer Treatment Centers of America® (CTCA)

The goal of a cancer screening is to identify cancer at an early stage, or as with some colonoscopies, to prevent it altogether by detecting and removing pre-cancerous cells. During a colonoscopy, doctors may remove polyps, which if left intact, may later develop into cancer.

Esophageal cancer

Risk factors: Those with a higher risk of esophageal cancer are:

  • Caucasian men
  • Aged 50 or older
  • Smokers
  • Those with a history of chronic acid reflux
  • Those who  have been diagnosed with Barrett’s esophagus

Recommendation: The ACS recommends high-risk patients have a regular upper endoscopy, which uses a thin tube to view the lining of the esophagus, stomach and duodenum.

Rationale: A key study on risk factors, screening and endoscopic treatment in Western and Eastern countries concluded that patients whose esophageal cancer was detected during endoscopic surveillance for Barrett’s esophagus “are more likely to have early-stage cancer, receive curative therapy, and survive longer” than patients who are not diagnosed until they have symptoms.

Liver cancer

Risk factors: You are considered high risk for liver cancer if you:

  • Have chronic viral hepatitis B or C
  • Have cirrhosis
  • Have type II diabetes
  • Have had long-term exposure to aflatoxins (cancer-causing  substances made by a fungus)
  • Use or have used an anabolic steroid for an extended period of time
  • Smoke

Recommendation: The ACS recommends screening only for those at highest risk, defined as patients with cirrhosis or chronic hepatitis B infection. Those patients should have a liver ultrasound and alpha-fetoprotein tumor marker (AFP) blood test performed every six to 12 months.

Rationale: Screening has been linked to improved survival rates in some studies.

Pancreatic cancer

Risk factors: Your risk increases for pancreatic cancer if you:

  • Have been diagnosed with late-onset diabetes (after age 40)
  • Are obese
  • Smoke
  • Use alcohol heavily
  • Have a family history of pancreatic cancer
  • Have a genetic mutation that is known to increase risk

Recommendation: Only people considered high risk—defined by the ACS as those with a strong family history of pancreatic cancer or a known genetic syndrome that increases the risk—are candidates for endoscopic ultrasound screening.

Rationale: Endoscopic ultrasound has identified “early, treatable pancreatic cancers in some members of high-risk families,” according to the ACS. Dr. Vashi also recommends that patients who meet all the risk factors undergo CT scans.

Gynecologic cancers

The risk factors and recommendations for cervical, ovarian, endometrial (uterine), vaginal and vulvar cancers vary widely by cancer type. However, some gynecologic cancers are caused by HPV (human papillomavirus) infections, which are sexually transmitted. The HPV vaccine, approved in 2006, is designed to protect against cervical, vulvar and vaginal cancers, as well as several other non-gynecologic cancers.

Cervical cancer

The Pap smear, a routine cervical swab performed in the doctor’s office, is “one of the most reliable and effective cancer screening tests available,” according to the ACS. Before the test’s introduction in the 1950s, cervical cancer was the “No. 1 cause of all cancer deaths in women,” says Julian Schink, MD, Chief of Gynecologic Oncology at Cancer Treatment Centers of America® (CTCA). “The Pap smear has been remarkably successful in the developed world, not just to prevent cervical cancer but for interventions before you get cancer. In the United States today, the biggest risk of cervical cancer is lack of screening.”

Risk factors: Your risk of developing cervical cancer increases if you have a history of:

  • Smoking
  • Multiple sexual partners
  • Multiple childbirths (three or more)
  • Long-term use of birth control pills (five years or longer)
  • HIV or another condition that compromises the immune system

Recommendations: The USPSTF recommends:

  • Pap smears every three years for women between 21 and 65 years old
  • Or, combined testing for women aged 30 to 65, including a Pap smear and HPV testing every five years

Rationale: “The Pap smear is really the prototype of screening tests because cervical dysplasia is a precancerous condition that women have if they have a persistent HPV infection,” says Dr. Schink. The combination of the HPV vaccine and the Pap smear has significantly decreased the rate of cervical cancer, according to the CDC.

Endometrial (uterine) cancer

Endometrial cancer is a form of uterine cancer that develops in the lining of the uterus. It accounts for more than 95 percent of uterine cancers.

Risk factors: The risk for developing endometrial cancer is higher in women who:

  • Are older (60 is the average age at diagnosis)
  • Are morbidly obese, defined as being 100 pounds overweight and having a body mass index (BMI) of 40 or more; or a BMI of 35 or more, combined with obesity-related health conditions, such as high blood pressure or diabetes
  • Have polycystic ovarian syndrome
  • Have hormone-level fluctuations resulting from estrogen use after menopause, birth control pills, the breast cancer drug tamoxifen or other factors.
  • Lynch syndrome

Recommendation: The ACS recommends that women who have or may have Lynch syndrome consider getting an endometrial biopsy every year beginning at age 35.

Rationale: To lower risk, ACOG and the SGO recommend women in their early to mid-40s consider a prophylactic hysterectomy and bilateral salpingo-oophorectomy, which removes the ovaries and the fallopian tubes.

Ovarian cancer

Risk factors: The ovarian cancer risk is highest in women who:

  • Are older (most cases are diagnosed in post-menopausal women)
  • Have a family history of ovarian cancer
  • Carry a BRCA1 or BRCA2 mutation, have Lynch syndrome or have any of the following other mutations: BRIP1, RAD51C or RAD51D
  • Have had endometriosis
  • Have never given birth or have had difficulty becoming pregnant

Recommendation: No reliable test has been developed to screen for ovarian cancer, but for women with an inherited gene mutation, the American Society of Clinical Oncology (ASCO) recommends discussing with your health care provider ways to reduce your risk, including:

  • Prophylactic (preventive) surgery to remove both ovaries (oophorectomy)
  • Prophylactic surgery to remove both the ovaries and the fallopian tubes (salpingo-oophorectomy)
  • Hysterectomy (removal of the uterus)
  • Tubal ligation

Vaginal and vulvar cancers

Risk factors: Your risk for vaginal and/or vulvar cancer increases if you have had:

  • A human papillomavirus (HPV) infection
  • History of cervical cancer or pre-cancer
  • Conditions or illnesses that compromised your immune system
  • Chronic vulvar itching or burning

Recommendations: The National Cancer Institute recommends the two-dose HPV vaccine series for:

  • Girls and boys beginning at age 11 or 12 (it can be given as early as age 9)
  • Females aged 13 through 26 and males 13 to 21 who were not previously vaccinated
  • Gay and bisexual men who have sex with other men, transgender people, and those with compromised immune systems

Rationale: The HPV vaccine provides protection against the deadly HPV subtypes 16 and 18. Some HPV vaccines also protect against other HPV subtypes, such as those that cause anal and genital warts. Getting the vaccine before being exposed to the virus is key. The vaccine cannot treat HPV once you become infected.

Lung cancer

Risk factors: The risk for developing lung cancer is categorized as high, moderate and low.

  • You are considered high-risk if you are:
    • At least a 30 pack-year smoker aged 55 to 74
    • A heavy smoker aged 55 to 74 who quit smoking fewer than 15 years ago 
    • At least a 20 pack-year smoker aged 50 or older with additional risk factors, such as radon exposure or prior treatment with radiation for another cancer, particularly head and neck cancer or lymphoma
  • You are considered moderate-risk if you are:
    • At least a 20 pack-year smoker aged 50 or older
  • You are considered low-risk if you are:
    • Younger than 50 and smoked less than 20 pack-years

While exposure to second-hand smoke is currently not included in the screening guidelines, Dr. Rich says that passive smoking, also known as second-hand smoke, increases the risk of lung cancer. The National Cancer Institute agrees, noting that "living with a smoker increases a nonsmoker's chances of developing lung cancer by 20 to 30 percent" and that some 3,000 nonsmokers die each year "as a result of exposure to secondhand smoke."

Recommendations: The USPSTF recommends low-dose CT scans for:

  • People aged 55 to 80 who have a 30 pack-year smoking history and currently smoke
  • Former smokers who quit smoking within the past 15 years (“Screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery,” the task force says.) 

In addition to the official recommendations, Patricia Rich, MD, Medical Oncology Director of the Lung Cancer Institute at CTCA®, says that if a nodule is found, low-dose CT scans should continue yearly, twice yearly or quarterly, depending on the size. Once the nodule is 1.5 cm or larger, it should be removed.

Rationale: Low-dose CT scans are used to detect nodules, or nodes, which are abnormal growths in the lung tissue. Dr. Rich says that preliminary diagnostic scans may help detect lung cancer in its early stages, instead of waiting until symptoms develop, which typically occurs when the disease has already progressed to advanced stages.

“In general, most lung cancer is diagnosed as advanced disease because there may not have been symptoms,” says Dr. Rich. “If someone comes to their primary care doctor with a chronic cough, and they are a heavy smoker, and a round of antibiotics doesn’t get rid of the cough, I’d do a low-dose CT scan. If they are coughing, short of breath and losing weight for no reason, that’s highly suspicious. Even if they’ve quit smoking.”

Prostate cancer

Risk factors: Those at higher risk for prostate cancer:

  • Are African American
  • Are at an advanced age
  • Eat a high-fat diet
  • Have a sedentary lifestyle
  • Have an immediate blood relative with prostate cancer
  • Have been exposed to Agent Orange
  • Have a BRCA1 or BRCA2 mutation

Recommendation: The ACS recommends that all men discuss with their doctor the risks and benefits of screening, including prostate specific antigen (PSA) blood tests and/or a digital rectal exam (DRE). These screening discussions should begin at age 50 for men at average risk who are expected to live at least 10 more years. Men at high risk—African Americans and men with a first-degree relative diagnosed with prostate cancer before age 65—should have these conversations at age 45. Those at an even higher risk—men with more than one first-degree relative who had prostate cancer at an early age—should initiate those talks even earlier, at age 40.

Rationale: Until 2012, a PSA test and a DRE had long been the standards in screening for prostate cancer, performed on men 40 and older. But on the heels of three large studies, the USPSTF concluded that screening was not warranted because the potential harms—false-positives, biopsy complications and over-diagnosis in 20 percent to 50 percent of men with clinically insignificant disease—outweighed the benefits. Over-diagnosis results in unnecessary treatment. Patients who undergo radiation therapy or surgery are at higher risk of chronic urinary issues and erectile dysfunction, and they may be at risk of a secondary cancer later in life, says Scott Shelfo, MD, Medical Director of Urology at our hospital near Atlanta. “It may not be an issue of over-screening, but an issue of over-treating," Dr. Shelfo says. "It's important to identify patients who are at the highest risk for prostate cancer and focus on treating those patients."

Another key: Know your genetic risks

It’s important to gather your family history and share the information with your doctors, says Eric Fowler, MS, LGC, Manager of Genetics Counseling at our hospital near Chicago. Clues that there may be an inherited risk for cancer in a family include: 

  • Two or more close relatives on one side of the family with the same or related cancers (such as breast and ovarian or colon and endometrial)
  • Cancers diagnosed before age 50
  • More than one cancer diagnosed in the same relative
  • A generation-to-generation pattern of cancer
  • Breast, ovarian or pancreatic cancer in someone with an Ashkenazi Jewish heritage

“If any of the above family history criteria are met, Fowler recommends seeing a licensed genetic counselor. A genetic counselor may help you understand how your personal and family history may impact cancer risks, help you measure your chances of an inherited risk in a family, and provide comprehensive information about genetic testing,” says Fowler.