Cancer Screening: Who, When and Why? Alison Plotzke, CCPA Physician Assistant Deanna Lautenbach, CCPA Physician Assistant Associate Clinical Professor

Disclosures We have no potential conflicts with this presentation We have no relevant financial relationships to disclose We will discuss both generic and brand name medications

Objectives To become familiar with the cancer screening options available for patients in Ontario To understand the benefits and potential risks involved with cancer screening To understand who to screen for each cancer and when it is appropriate to start and stop screening

Background What does the term screening mean? What types of cancer screening are available in Ontario? Cancer screening refers to trying to detect cancer when symptoms are not present. It is import to differentiate this from investigation which can be done if a patient presents with symptoms that concern you that may have cancer.

Mary What type of screening is she due for? What questions would you like to ask Mary

Cancer Screening Cervical Cancer: Last PAP 3 years ago Normal Breast Cancer: Mammogram 2 years ago: normal

Cervical Cancer Screening FAQ When do you start: Age 21 or when sexually active (whichever comes first) When do you stop: Age 69 as long as the past 3 PAPs have been normal What if my patient has had a hysterectomy? Full hysterectomy for benign disease do not require repeat PAPs What if my patient is pregnant? Continue on the same schedule (q3year as long as normal PAP) What if my patient is transgender? Transgender males who have retained their cervix should be screened according to the guidelines Oncogenic strains of HPV

Mary’s Next PAP Comes back showing LSIL

What if Mary’s PAP comes back abnormal? LSIL Low grade squamous intraepithelial lesion We use the Ontario Cervical Cancer Screening Guidelines to help us decide what to do with an abnormal Pap. The except on this slide is taken from this document. We know what Mary’s last PAP was normal. This PAP shows LSIL. Using these guidelines we know we need to repeat May’s PAP again in 6 months. If the repeat is normal we repeat it one more time at the 6 month interval and then she can return to normal screening. It is it abnormal we refer to colposcopy

What about vaccination? National Advisory Committee on Immunization recommends giving the Gardasil vaccine to Females ages 9-45 and males ages 9-26. Many gynecologists recommend giving it everyone, especially those with abnormal PAPs even outside of the recommended age range. Gardasil 9 protects against the 9 most common stains of the HPV virus: 6, 11, 16, 18, 31, 33, 45, 52, and 58 Merck Canada Inc. 2016 NACI recommends Gardasil 9 for females 9-45 and males 9-26.

Breast Cancer Screening FAQ Who is high risk? BRCA 1 and BRCA 2 carriers First degree relatives of BRCA1/2 carries who have declined genetic testing Have received chest radiation before age 30 High risk patients should be screened annually with mammogam and/or MRI between age 30-69 When should I screen my average risk patients? q2 years between 50 and 74;lkj;klj;klj What if my 45 year old patient requests a mammogram? Optional between 40-49 Associated with more false positive test results False positive test results lead to invasive and potentially harmful follow-up procedures Anticipate a new guideline in 2018 Mention the Ontario Breast Screening Program

Breast Cancer Screening FAQ What are the risks of Mammography? Radiation False Positives Unnecessary testing and invasive procedures Increased anxiety What are the benefits? Modestly reduces the number of deaths from breast cancer Ages 50-74 have the strongest benefit Mammography is a type of x-ray so there is a small amount of radiation exposure for the patient.

Peter 58 year old male Healthy Last seen 9 years ago Presenting to the doctor’s office “because his wife told him to”

Peter What type of screening is Peter due for? What questions would you like to ask Peter?

Peter No history of colorectal cancer (CRC) screening No bowel changes No constitutional symptoms No family history of prostate cancer or CRC No urinary symptoms Non-smoker

CRC Screening FAQ Who do we screen? Average risk individuals ages 50-74 How do we screen? OBT q2 years OR Flexible sigmoidoscopy q10 years Who is high risk? Previous colon cancer of polyps Mention what happens in practice – colonoscopy Mention that high risk patients do not adhear to the guidelines, they are for healthy asymptomatic patients only Add FOBT picture and flex sig picture

CRC Screening FAQ Peter chooses to use a FOBT kit which is sent home with him He will place the kit in the mail when it is completed

Prostate Cancer Screening FAQ How do we screen? Controversy over the PSA and DRE Deanna to send Alison Jason’s paper

Prostate Cancer Screening FAQ Screening programs for prostate cancer are a widely debated topic There is considerable inconsistency in current guidelines Controversy over the PSA and DRE Deanna to send Alison Jason’s paper

The Guidelines Canadian Task Force on Preventative Health We recommend not screening for prostate cancer with the PSA test Cancer Care Ontario (CCO) Given the potential harms of screening, including over-diagnosis and over-treatment, CCO does not support an organized, population-based screening program for prostate cancer Canadian Urological Association Prostate cancer screening should be offered to all men 50 years of age with at least a 10-year life expectancy American Academy of Family Physicians Do not routinely screening for prostate cancer using a PSA test or DRE American Urological Association Offer PSA screening for prostate cancer only after engaging in shared decision making Controversy over the PSA and DRE Deanna to send Alison Jason’s paper Adapted from Am Fam Physician, 2015; Canadian Task Force, 2014; Cancer Care Ontario, 2015

Risks and Benefits What are the risks of prostate cancer screening? What are the benefits of prostate cancer screening? DRE low sensitivity, low specificity, high examiner bias

Prostate Cancer Screening FAQ Among men ages 55 to 69 who do not get screened, the risk of dying from prostate cancer is 6 in 1,000. With regular PSA screening, the risk of dying from prostate cancer among men aged 55 to 69 may be reduced to 5 to 1,000. ISN’T IT BETTER TO GET SCREENED THAN TO DO NOTHING? Screening with the PSA ofter leads to further testing, which carries with it its own serious risks and problems. For example, a biopsy involves a number of potential harms such as infection, blood in the urine, or even death. Additionally, if testing leads to treatment, such as a prostectomy (removal of the prostate gland), the chances of urinary incontinence and erectile dysfunction significantly increases. Other short term post-surgical complications include infections, additional surgeries and blood transfusions and death. Canadian Task Force, 2014

Bottom Line PSA Not useful as a screening tool DRE Controversy over the PSA and DRE Deanna to send Alison Jason’s paper

Summary Cervical Cancer PAP every 3years Ages 21-69 Breast Cancer Mammogram every 2years Ages 50-74 Colorectal Cancer FOBT ever 2 years or flex sig every 10 years Ages 50-74 Prostate Cancer Don’t screen Controversy over the PSA and DRE Deanna to send Alison Jason’s paper

Thank you