3. American Congress of Obstetricians and Gynecologists (ACOG) recommends:
a. Age 20 to 39: CBE every 1 to 3 years.
b. Age 40 and over: annual CBE and annual mammography.
c. Over age 75 the decision to screen should be individualized.
d. “Breast self-awareness should be encouraged and can include BSE.”
G. BRCA1 and BRCA2 germline mutations substantially increase the risk that a woman will develop breast cancer over her lifetime (J Natl Cancer Inst 2013;11:812).
1. BRCA 1 carriers have a 60% cumulative risk of breast cancer by age 70.
2. BRCA2 carriers have a 55% cumulative risk of breast cancer by age 70.
3. The USPSTF makes no recommendations for screening women at high risk.
4. The ACS recommends women that very high risk (>20% lifetime risk) or with BRCA1 or BRCA 2 gene mutation should undergo magnetic resonance imaging (MRI) screening and mammography every year. For most women at high risk, screening with MRI and mammograms should begin at age 30. Women at moderately increased risk (15% to 20% lifetime risk) should talk to their physicians about the benefits and limitations of MRI screening in addition to yearly mammography.
5. ACOG recommends women at very high risk (>20% lifetime risk) should have “enhanced screening” with annual mammography, CBE every 6 to 12 months, instruction in BSE, and possibly MRI.
6. The National Comprehensive Cancer Network (NCCN) recommends the following for BRCA-positive women who have not undergone risk reducing mastectomy:
a. Consideration of monthly BSE starting at age 18.
b. CBE every 6 to 12 months beginning at age 25.
c. Annual mammography and breast MRI beginning at age 25.
III. CERVICAL CANCER SCREENING
A. The effectiveness of cervical cancer screening has never been studied in a randomized trial but is supported by strong epidemiologic evidence. Most cases of cervical cancer occur in unscreened or inadequately screened women.
B. Cervical cytologic screening may be done with the conventional Pap smear or with liquid-based tests (method does not change screening frequency).
C. HPV vaccination does not change the screening guidelines.
D. The ACS, USPSTF, and ACOG have similar recommendations, as summarized below.
E. Do not begin screening until age 21 years regardless of sexual history.
1. Under age 21, cervical cancer is quite rare (1 to 2 per million), while HPV infection is common and dysplasia may occur, but both usually spontaneously remit.
F. Women aged 21 to 29 years should be screened every 3 years with cytology only. (HPV testing would detect many transient infections without carcinogenic potential.)
G. Women aged 30 and older may be screened by cytology plus HPV cotesting every 5 years (preferred), or with cytology alone every 3 years.
H. Women who have had a total hysterectomy (including removal of the cervix) for benign disease may stop cervical cancer screening.
I. Screening may be stopped at age 65 in women who have had adequate screening (three consecutive negative Pap tests or two consecutive negative HPV/Pap cotests within past 10 years, and most recent test within 5 years).
J. Risk factors and special cases:
1. In women with HIV infection, the CDC recommends cervical cytology screening twice in the first year after diagnosis and annually thereafter, while ACOG recommends annual cytology starting at age 21.
2. ACOG recommends that women with a history of high-grade dysplasia or cancer should continue routine age-based testing for 20 years, even past age 65.
3. More frequent screening may be required in women with a history of prenatal exposure to diethylstilbestrol (DES) and women who are immunocompromised (such as organ transplantation).
IV. COLORECTAL CANCER SCREENING
A. Colorectal cancer (CRC) is the second most common cause of cancer deaths in the United States. Screening is associated with decreases in incidence as well as mortality, due to removal of premalignant adenomatous polyps, but only about two-thirds of Americans have been screened adequately (N Engl J Med 1993;329:1977).
B. Screening strategies fall into two main categories:
1. Stool-based tests that primarily detect cancer: guaiac-based fecal occult blood testing (gFOBT), fecal immunochemical test (FIT), or stool DNA testing.
2. Tests that detect both cancer and adenomatous polyps, thus permitting polyp removal for cancer prevention: flexible sigmoidoscopy (FSIG), colonoscopy, barium enema, or CT colonography.
C. For any test other than colonoscopy, any abnormalities must be followed up with a full colonoscopy, not just repeat testing.
D. A brief summary of screening tests and recommended intervals includes the following:
1. Annual gFOBT has modest sensitivity and specificity, but has been shown in randomized controlled trials to lower CRC mortality. It should be done with a high-sensitivity test such as Hemoccult SENSA on three specimens collected at home (in-office rectal exam is not an acceptable stool test for CRC screening).
2. Annual FIT that detects human globin from lower GI bleeding (globin from upper GI sources is digested) and is therefore more specific.
3. Stool DNA test, interval uncertain.
4. FSIG every 5 years has been shown to lower CRC mortality despite only examining the distal colon. It requires a limited bowel prep, and no sedation is required. Colonic perforation is rare (<1 in 20,000).
5. Air contrast barium enema (ACBE) every 5 years has only half the sensitivity of colonoscopy. It requires a full bowel prep, no sedation is used, and the test may be uncomfortable.
6. Computed tomography colonography (CTC) or “virtual colonoscopy” every 5 years.
a. Requires a full bowel prep and air insufflation.
b. Sensitivity is probably comparable to colonoscopy.
c. Patients with large polyps must be referred for colonoscopic resection, but uncertainty exists about management of small (<6 mm) polyps.
7. Colonoscopy every 10 years.
a. Requires a full bowel prep and sedation.
b. Regarded as the gold standard, but may miss 5% to 12% of lesions >1 cm.
c. Lesions can be resected during the procedure.
d. Risk of colonic perforation is about 1 in 1,000; can also cause bleeding and cardiovascular complications.
E. Current guidelines were published in 2012 by the American College of Physicians (ACP) (Annal Intern Med 2012;156:378), in 2008 by the USPSTF (Annal Intern Med 2012;156(5):378), and in 2008 by a joint guideline (CA Cancer J Clin 2008;58:130) published by ACS, the United States Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology.
F. The USPSTF recommendations include the following:
1. Screen adults aged 50 to 75 using annual high-sensitivity gFOBT, or FSIG every 5 years combined with high-sensitivity gFOBT every 3 years, or colonoscopy every 10 years.
2. Do not routinely screen those aged 76 to 85 years, but there may be considerations that support screening in an individual patient.
3. Screening is not recommended >85 years of age.
G. The ACP recommends that
1. Clinicians perform individualized assessment of risk for CRC in all adults.
2. Average-risk adults should start CRC screening at age 50, using annual gFOBT, annual FIT, FSIG every 5 years, or colonoscopy every 10 years.
3.
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