CANCER SCREENING

Sudarsa
Department of Surgery, Faculty of
Medicine University of Udayana /
Sanglah General Hospital Denpasar
2012

COLORECTAL CANCER

INTRODUCTION
Cancer is a major public health problem in
the developed countries.
The second leading of death after
Cardiovascular disease.
One of WHO priority program for cancer
control is Cancer screening.
Screening for Cancer: whats new and
controversies?

W.H.O. Priority Program for

Cancer Control.
Primary Prevention ( Public Education, Professional
Education, Political Will Government)
Secondary Prevention ( Early Detection screening
program: Individual & Mass Screening).
Tertiary Prevention (Correct Diagnosis and prompt
treatment) good professional training and
education patient volume, and learning curve
first appropriate attempt for treatment the best
chance for cure.
Palliative Management especially pain
management.

PRINCIPLES OF CANCER
SCREENING
Screening test is performed on asymptomatic
individual to determine that cancer might be
present and that further evaluation is necessary.
Screening must find disease earlier and lead to an
efficacious treatment.
Earlier use of the efficacious treatment must offer
better outcome.
The ultimate purpose of screening is to reduce
mortality.
Potential bias of screening: Selection, Lead-time,
length-time bias.

TYPE OF SCREENING FOR

CANCER
INDIVIDUAL SCREENING
MASS SCREENING

Screening Test VS Diagnostic

Test
Screening test:
- Initiated by providers
- Easy and quick
- Cheaper
- High sensitivity and
specificity
- Acceptable by
community
- For large population
- Followed by further
diagnostic test

Diagnostic test
- Initiated by patients
- From easy to
sophisticated
- More expensive
- High accuracy
- May not accepted
- Especially for individual
- Not followed by any test

Characteristic of the Ideal

Screening Program
Features of the disease:
Significant impact on public health
Asymptomatic period during which detection is possible
Outcome improved by treatment during asymptomatic period
Feature of the test:
Sufficiently sensitive to detect disease during asymptomatic
period
Sufficiently specific to minimize false positive test results
Acceptable to patients
Features of screened population:
Sufficiently high prevalence of the disease to justify screening
Relevant medical care is accessible
Patients willing to comply with further work-up and treatment
From: Gates JT. Screening Cancer: Evaluation of Evidence. Am Fam Physician 2001;63:513-22 .

Potential Biases of Screening

Several biases of screening: Selection, Lead-time,
Length-time bias.
SELECTION BIAS:
Occurs when a group of individuals comes
forward to be screened.
The individuals are at higher risk getting cancer,
The individuals have better underlying health.

Lead time bias:

Occurs when the asymptomatic period in the
natural history of the disease is not taken into
account.
Survival statistics prone to lead-time bias
The time from diagnosis to death is increased
Treatment does not prolong overall life
The patient does not live longer
The patient is merely diagnosed at an earlier
date.
The Scheme

LEAD TIME BIAS

From: Gates JT. Screening Cancer: Evaluation of Evidence. Am Fam Physician

2001;63:513-22.

Length time bias:

Occurs because of heterogeneity of diseases.
Occurs when slow-growing, less aggressive
cancer are detected during screening.
Interval Cancers are more aggressive, and
treatment outcomes are not favorable.
The scheme:

LENGTH TIME BIAS

From: Gates JT. Screening Cancer: Evaluation of Evidence. Am Fam Physician 2001;63:513-22 .

SCREENING FOR CERVICAL

CANCER

PAPANICOLAOU (PAP) SMEAR

- Prototype of a successful cancer screening program
- 80% decrease in mortality caused by cervical cancer
- Recommended interval 1-3 years
- Regularly for women who are sexually active over age 18 yrs
- ACS: Begin 3 yrs after the onset of vaginal intercourse.
- NO RCTs

New methode: Liquid based Pap test

Asetic Acid
HVP-DNA test.

Current controversies: Proper interval of Pap smear, when to stop.

Role of new technology
HPV
Vaccine ???

SCREENING FOR BREAST CANCER

Study of BSE and CBE have not shown a decrease in
mortality (Cochrane review)
Mammographic screening normal-risk women over 50 years
every 1 year decrease mortality 20-30%.
Mammographic screening for women aged 40-49 years, still
controversy. (Meta-analysisno benefit of mammographic
screening)
High breast density is associated with diminished sensitivity.
Women at high risk: Earlier initiation, short interval, and
with add modalities (MRI).
Mammographic screening may not sensitive in women
carrying BRCA1/BRCA2 gene mutations.
See ACS guidelines

SCREENING FOR COLORECTAL

CANCER
ACS guideline for colorectal screening.
RCTs for FOBT 33% reduction in RR of death.
other RCTs 15-18%.
FOBT and FIT
No RCTs for Flexible sigmoidoscopy
DRE or Barium enema as CRC screening?
New methods: Virtual colonoscopy or CT
colonography. DNA methylation, Gene mutation.
The role of screening in high risk population?
Controversy: high cost.

SCREENING FOR PROSTATE

CANCER
DRE and PSA, annually, starting at age 50 years.
Prostate cancer prone to lead-time bias, length
bias, and over diagnosis.
There was insufficient evidence in support of
prostate cancer screening.
PSA: prostate tissue specific. Normal level 04ng/dL. Cutoff value for screening 2,5ng/dL?
ACS recommendation: Normal-risk men > 50
years be offer screening and be allowed to make
choice after being informed of potential risks and
benefits of screening.

Screening for Lung Cancer

No standard screening methods for lung cancer
Chest x-rays, sputum cytology or both.
No reduction in mortality was seen in screened
population (Cochrane review)
Spiral CT screening and PET as adjunct to spiral
CT in asymptomatic smokers
ACS: no recommendation of screening for lung
cancer.

Brawley OW, Kramer BS. Cancer Screening in Theory and in Practice. J Clin Oncol 2005;23:293-300.

Gates TJ. Screening for Cancer: Evaluating the Evidence. Am Fam Physician 2001;63:513-22.

PRECANCEROUS LESIONS

CHEMOPREVENTION ?

SUMMARY
The important role of primary care provider in cancer
screening.
A screening test is performed on an asymptomatic
individual and more complicated than diagnostic test.
The purpose of screening is to reduce mortality
Understanding of evidence and potential bias of
screening.
Advances in cancer biology and medical imaging
have led to number of cancer screening test.
In the future, proteomic technology also can be used
for cancer screening.

EDUCATION IS STRONGEST
WEAPON AGAINST CANCER