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Cancer screening

This page was reviewed under our medical and editorial policy by

Ruchi Garg, MD, Chair, Gynecologic Oncology, City of Hope Atlanta, Chicago and Phoenix.

This page was reviewed on March 17, 2023.

Breast self-exams, Pap smears, PSA screeningsgenetic testscolonoscopies—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.

Who should be screened for which cancer types?

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, with the number of new cancer diagnoses remaining largely unchanged but with a slightly downward trend in recent years, according to the National Cancer Institute (NCI). The American Cancer Society (ACS) expects nearly 2 million (1,958,310) new cases of cancer to be diagnosed in 2023. At the same time, more and more people are surviving longer with cancer. The ACS reports that the five-year relative survival rate for all cancers has increased dramatically since the early 1970s—improving from 49 percent to 68 percent for diagnoses made during 2012 through 2018, though for almost all cancer types, lower survival rates persist among African Americans compared to white people. Cancer-related deaths also continue to drop steadily, according to the ACS. The rate of death from cancer for both men and women fell 33 percent from its peak in 1991 to 2020, the most recent year for which data is available. This means that nearly 3.8 million fewer people died from cancer during these years than would have been expected had the death rate not fallen. 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). Namely, the guide will cover the three R's for:

If you're interested in scheduling a cancer screening at City of Hope, or it you believe you have symptoms of cancer and want to schedule an appointment for a diagnostic evaluation, call us or chat online with a member of our team.

Breast cancer screening

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: BRCA1BRCA2, 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 and screening tests: The leading cancer organizations differ on breast cancer screening guidelines.

  • The USPSTF recommends that average-risk women between the ages of 40 and 49 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 are at higher risk and 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 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, instead 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.

For healthy women with no family history of breast cancer, City of Hope experts recommend beginning annual mammograms between ages 40 and 45 and continuing until age 70, then getting the tests every other year. Women should also get a 3D mammogram when possible because it provides a clearer picture, especially of dense breasts.

Breast MRI screening is typically reserved for “very high-risk women” who carry inherited gene mutations, such as BRCA1, BRCA2 or Li–Fraumeni Syndrome. In those cases, women should get 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. We strongly recommend these women undergo genetic testing since Ashkenazi Jewish women are at an increased risk of having a BRCA mutation.

The most important recommendation here 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.

Gastrointestinal (GI) cancer screening

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: colorectalesophagealliver, and pancreatic.

Colorectal cancer screening

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

  • Age (more common in patients 45 and older)
  • Obesity and type II diabetes
  • Sedentary lifestyles
  • Tobacco use
  • Moderate to heavy alcohol use
  • Personal history of colorectal polyps or family history of colorectal cancer
  • African American or Ashkenazi Jewish heritage
  • Type 2 diabetes
  • History of inflammatory bowel disease (IBD), colitis or Crohn’s disease
  • Lynch syndrome or other inherited gene mutations

Recommendations and screening tests: Colorectal screening 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 colon 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 IBD, 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.

Note: In October 2020, the USPSTF recommended lowering the age to begin colorectal cancer screenings from 50 to 45. In doing so, the USPSTF, an independent body of medical experts tasked with making evidence-based recommendations about preventative clinical services, joined the American Cancer Society (ACS), which since 2018 has recommended starting screenings at age 45.

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 City of Hope Atlanta, Chicago and Phoenix.

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 screening

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 and screening tests: 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.

Rationalekey 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 screening

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

  • Have chronic viral hepatitis B or C
  • Have cirrhosis
  • Have type 2 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 and screening tests: 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.

RationaleScreening has been linked to improved survival rates in some studies.

Pancreatic cancer screening

Risk factors: Your risk increases for pancreatic cancer with:

  • Type 2 diabetes
  • Obesity
  • Tobacco use
  • Chronic pancreatitis
  • A family history of pancreatic cancer
  • A genetic mutation that is known to increase risk

Recommendation and screening tests: 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 or MRI 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 cancer screening

The risk factors and recommendations for cervicalovarian, endometrial (uterine), vaginal and vulvar cancers vary widely by cancer type. However, some gynecologic cancers are caused by human papillomavirus (HPV) 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 screening

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, Gynecologic Oncologist at City of Hope Phoenix. “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)
  • HPV
  • HIV or another condition that compromises the immune system (such as an organ transplant)

Recommendations and screening tests: 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 screening

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 increases for women who meet any of the following criteria:

  • Are older (60 is the average age at diagnosis)
  • Have had no prior pregnancies
  • Have experienced an increased number of menstrual cycles (including individuals who started their periods before age 12 and those who went through menopause after age 50)
  • Are obese
  • Have metabolic syndrome
  • Have endometrial hyperplasia (a buildup of cells and glandular structures that causes thickening in the endometrium)
  • Have a history with polycystic ovarian syndrome (typically with metabolic syndrome)
  • Have had estrogen replacement therapy without progesterone
  • Have taken tamoxifen for treatment
  • Have been diagnosed with Lynch syndrome

Recommendation and screening tests: Currently, there is no standard or routine screening recommendation for endometrial cancer when there are no symptoms. Screening tests for endometrial cancer are being studied.

The NCI recommends that women with abnormal vaginal bleeding have tests to check for cancer, such as:

  • An endometrial biopsy to examine endometrial cells
  • A transvaginal ultrasound, which places an ultrasound probe in the vagina, allowing health care providers to examine the uterus and other organs in the pelvis.

Pap tests may sometimes detect abnormalities in the endometrium during routine testing, but it’s mostly an incidental finding that’s followed up with further testing.

Additionally, the ACS advises women who have (or may have) hereditary non-polyposis colon cancer (HNPCC, or Lynch syndrome) to consider yearly testing for endometrial cancer with endometrial biopsy starting at age 35. The NCI says that for those with, or possible risk of, HNPCC, yearly screening with transvaginal ultrasound may begin as early as 25.

Ovarian cancer screening

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

  • Are older (most cases are diagnosed in post-menopausal women)
  • Have a previous diagnosis of breast cancer
  • 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 and screening tests: 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:

Vaginal and vulvar cancer screening

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 and screening tests: The National Cancer Institute recommends the two-dose HPV vaccine series for:

  • Girls and boys between the ages of 9 and 26, two doses for those younger than 15, and three doses for those older
  • FDA approved up to age 45 but recommend individualized discussion with a provider
  • 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 screening

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 50 to80
    • A heavy smoker (30+ pack-years) aged 50 to 80 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 a20 pack-year smoker aged 50 or older
  • You are considered low-risk if you are:
    • Younger than 50 and have smoked fewer than 20 pack years

While exposure to second-hand smoke is currently not included in the screening guidelines, passive smoking, also known as second-hand smoke, increases the risk of lung cancer., according to the National Cancer Institute, which notes 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 and screening tests: 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 lung cancer screening recommendations, City of Hope experts recommend 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. 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.

Prostate cancer screening

Risk factors: Risk for prostate cancer increases among men who:

  • 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 and screening tests: 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 start 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."

Hereditary cancer screening: 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)
  • A family member with a BRCA1/2 or another cancer susceptibility gene (including PTEN, PALB2 or TP53)
  • 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, I recommend 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.

Cancer screening at City of Hope

When you come to City of Hope for cancer screenings—for breast, colorectal or lung cancer—you'll have access to tests that may help increase the accuracy of the screening tools provided. Our team has expertise with these tests and procedures, allowing us to work quickly and efficiently.

If you’re diagnosed with cancer, a multidisciplinary team of experts—which depending on your cancer type may include a medical oncologist, surgical oncologist, radiation oncologist and disease-specific experts such as a breast surgeon or a urologic oncologist—will review your case and develop a personalized plan based on your specific circumstances and needs.

We only treat cancer at City of Hope, which means our cancer experts are skilled at assessing risk associated with each person’s circumstances. We give you the pros and cons of the treatment options available to you, allowing you time to talk with your team of doctors and other experts about those options.

If you choose to receive treatment with us, you may benefit from our integrative approach to cancer treatment. Our multidisciplinary team works together to help prevent and manage the side effects of cancer and its treatment, providing supportive care services, such as:

Regular screenings are critical to reducing your cancer risk, allowing you to prevent cancer when possible, in the case of cervical cancer with the Pap smear or colorectal cancer with colonoscopies, or to help catch the disease in its earlier stages, when it is easier to treat. No matter where you get your screenings, make them a regular part of your wellness plan and keep your calendar up to date with reminders, if necessary.

If you're interested in scheduling a cancer screening at City of Hope, or it you believe you have symptoms of cancer and want to schedule an appointment for a diagnostic evaluation, call us or chat online with a member of our team.

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