CANCER SCREENING

Sudarsa
Department of Surgery, Faculty of Medicine
University of Udayana / Sanglah General Hospital
Denpasar 2011
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: what’s 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: Diagnostic test

- Initiated by providers - Initiated by patients
- Easy and quick - From easy to
sophisticated
- Cheaper - More expensive
- High sensitivity and - High accuracy
specificity
- Acceptable by community - May not accepted
- For large population - Especially for individual
- Followed by further diagnostic - Not followed by any test
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-analysisno 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 0-4ng/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