Screening and Prevention for Cancer:

Breast, Prostate, Colon

IV Curso Internatcional de
Actualizaciaon y Preparacion del
Board de Medicina Interna
November 2011
Scott Okuno, MD
Mayo Clinic

Screening

Breast
Prostate
Colon

Breast Cancer Screening

36 year female comes to your office for routine

physical

Clinical exam is normal including breast exam

Family history is positive for mother with breast
cancer, maternal aunt with ovarian cancer, and
maternal grand mother with breast cancer

Recommendation for breast cancer screening

What imaging?
What other testing?

Hereditary Breast Cancer

Less than 20% of breast cancers are hereditary

BRACA1 and BRACA2
<1 % population
5-6 % breast cancer
Risk of breast cancer by age 70
BRACA 1 47-66%
BRACA 2 40-57%

Who Should Get Testing For BRACA 1, 2?

Family history of breast or ovarian cancer

Young onset of breast or ovarian cancer
Ashkenazi Jews

Hereditary Breast And Ovarian Cancer

Mammography
Breast MRI
More sensitive than mammography
Less specific than mammography
Breast cancer detected at earlier stage
CA 125 and Vaginal Ultrasound

Risk Reduction Strategies

Bilateral prophylactic mastectomy

Bilateral salpingo-oophorectomy
Chemoprevention
Tamoxifen
(No data on aromatase inhibitors or SERM)

UpToDate

High Risk Factors

BRACA 1 and BRACA 2

Older Age >70
High breast density
High bone density
History of prior Atypical hyperplasia biopsy

Breast Cancer Prevention

40 year old female otherwise healthy

Sister diagnosed with breast cancer at age 45
BRACA 1 and 2 negative
Does not want Prophylactic Mastectomy
What options are available?
Tamoxifen
Raloxifene
Aromatase inhibitor

Breast Cancer Prevention Trial (P-1)

Tamoxifen vs Placebo
At increased risk
60 year or older
35-59 with Gail Risk of >1.65
http://www.cancer.gov/bcrisktool/
35 years old with history of LCIS

Breast Cancer Prevention Trial (P-1)

Tamoxifen reduced the risk of invasive breast

cancer by 43% (2.5 vs 4.3 %)

No difference in overall survival or breast

cancer-specific survival

Increase risk of Stroke and PE age 50 or older

Increase risk of DVT in all age groups

Meta-Analysis of 4 Breast Prevention

Studies

Tamoxifen reduces invasive breast cancer (1.7

vs 2.6 percent)

Benefit last 3-5 years after discontinuation

No reduction in breast cancer mortality
No reduction in overall mortality

Raloxifene vs Tamoxifen (STAR)

Tamoxifen better than Raloxifene at reducing

invasive breast cancer
4.09 and 4.47 per 1000 age 50-59 and > 60
5.03 and 5.49 per 1000 age 50-59 and > 60

Fewer thromboembolic events with Raloxifene

Risk of invasive uterine ca less with Raloxifene
1.23 vs 2.25 per 1000

Prostate Cancer Screening and Prevention

Recommendations
PSA to begin at age 50 (40-45 in African

American, + Family history, or BRACA1)

Stop screening around age 75
Assuming life span > 10 years
Repeat every 2-4 years

Prostate Cancer Screening

45 year old male whose father at age 70 was

diagnosed with prostate cancer has a reviewed
the data and wants to be screened and a PSA
is 7 ng/mL

Age Specific ranges:

40-49 - 0 to 2.5 ng/mL
50-59 - 0 to 3.5 ng/mL
60-69 - 0 to 4.5 ng/mL
70-79 - 0 to 6.5 ng/mL
Your next step?

Things That Affect PSA

Decrease PSA
5-alpha-reductase

inhibitors
NSAIS and
Acetaminophen
Statins
Thiazides

Increase PSA
BPH
Prostate CA
Prostatic inflammation
DRE (clinically

insignificant)
Cyclist
Sexual activity

PSA Additional Tests

PSA velocity
PSA density
Free and bound PSA (when PSA is in the
normal range)

Prostate Cancer Prevention

Follow up PSA is 3.5 ng/mL

Patient interested in prevention of prostate
cancer

What are his options?

5-Alpha Reductase Inhibitors
Statins
Vitamins
E, D, Selenium

Prostate Cancer Prevention Trial (PCPT)

Finasteride (type 2 5-AR inhibitor)

Age > 55 or
African-American ethnicity or
First degree relative with prostate cancer
Normal DRE and PSA < 3 ng/mL
18,882 men
Annual PSA > 4 ng/mL bx recommended

Dutasteride in Prostate Cancer Prevention

5-AR type 1 and 2 inhibitor (suppresses DHT >

90 % compared to finasteride 70%)

Decreases incidence of prostate cancer

(25.1 % vs 19.9%)
Decrease in those with lower Gleason scores
Side effects:
Erectile disfunction (9.0% vs 5.7%)
Decrease libido (3.3% vs 1.6%)
Gynecomastia (1.9% vs 1.0%)

Prostate Cancer Prevention Trial (PCPT)

25% decrease in the incidence of prostate CA

Increase in the more aggressive prostate CA
(Gleason > 7) in the finasteride group

Only 5 men in each group died of prostate CA

Colon Cancer Screening

48 year old female

She in interested in colon cancer screening
What additional questions are important?
Personal history of colon polyps
Family history of colon cancer
History of colon cancer
Inflammatory bowel disease

Colon Cancer Screening

Higher Risk
Hereditary nonpolyposis colon cancer
Familial adenomatous polyposis
Prior history of adenomatous polyps
Active inflammatory bowel disease
Family history of colorectal cancer
Race Black persons

Screening Options (Tool) and Frequency

Colonoscopy (every 10 years)

Virtual Colonoscopy (every 5 years)
Flexible sigmoidoscopy (every 5 years)
Double contrast barium enema (every 5 years)
Fecal occult blood (annually x 3 and special
diet)

Fecal immunochemical (FIT) for blood

(annually x 2-3 no special diet)

Recommendations: US Preventive Service

Task Force and American Cancer
Society/Multi-Society Task Force
USPSTF
ACS-MSTF
Screening ages 50-75
Screening at age 50
until life expectancy <
Annual FOBT
10 years
Flex sig every 5 years
Testing options open
and FOBT every 3

years
Colonoscopy every 10
years

Colon Cancer Prevention Options

48 Year old female with average risk of colon

cancer has a co-worker dying of colon cancer
and want to try to prevent a colon cancer
developing.

What are her options

Aspirin and NSAIDs
Others

Meta-Analysis of Studies of
Aspirin/NSAIDS

Regular use of ASA reduced incidence of

colonic adenomas

Reduction in the incidence of colorectal cancer

Longer duration of use > 6-10 years
Consistent use
USPSTF Guidelines 2007
Overall the harms outweighed the benefits of
ASA and NSAID and recommended against
the routine use of ASA and NSAID to
prevent colon cancer in ave risk and + FHX