Preventive Cancer Screenings: Breast, Ovarian and Prostate Cancer

Cancer screening is a big debate in this country. The U.S. Preventive Services Task Force has many different guidelines and often change them. 

For example, they currently recommend against PSA screening for prostate cancer in men under the age of 55. 

• Gives PSA screening grade D - meaning that there is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits
• Recommendation was first issued in 2011

WHAT’S WRONG WITH US TASK FORCE RECOMMENDATION

• It focuses on complications of treatment—incontinence & erectile dysfunction—but not on the value of screening and the amount it has saved the healthcare system
• Discusses population screening, but ignores African Americans, the effect of family history, and morbidity associated with prostate cancer
• No one on the task force has actually treated patients with prostate cancer
  • Task force is made up of 16 volunteer members who are experts in prevention, evidence-based medicine, and primary care
  • Their fields of practice and expertise include behavioral health, family medicine, geriatrics, internal medicine, pediatrics, obstetrics and gynecology, and nursing
• Prostate cancer mortality was on the decline before the task force issued its recommendation
• ·Task force failed to take into account evolving trends in the thinking of urologists regarding the PSA testing and prostate cancer treatment
• Recommendation has also affected policy - some commercial payers are denying coverage for PSA testing
  • Will affect patient outcomes in the long run
• Decisions are being made without proper input from the specialists who treat these diseases
  • Prostate cancer mortality was on the decline before the task force issued its recommendation
• Since PSA testing, we have seen a 40% reduction in prostate cancer mortality in the United States

PROS AND CONS OF PROSTATE CANCER SCREENING

PROS

• PSA screening may help you detect prostate cancer early.
• Cancer is easier to treat and is more likely to be cured if it's diagnosed in the early stages of the disease
• PSA testing can be done with a simple, widely available blood test. 
• For some men, knowing is better than not knowing. Having the test can provide you with a certain amount of reassurance — either that you probably don't have prostate cancer or that you do have it and can now have it treated.
• The number of deaths from prostate cancer has gone down since PSA testing became available.

CONS

• Some prostate cancers are slow growing and never spread beyond the prostate gland.
• Not all prostate cancers need treatment. Treatment for prostate cancer may have risks and side effects, including urinary incontinence, erectile dysfunction or bowel dysfunction.
• PSA tests aren't foolproof. It's possible for your PSA levels to be elevated when cancer isn't present, and to not be elevated when cancer is present.
• A diagnosis of prostate cancer can provoke anxiety and confusion. Concern that the cancer may not be life-threatening can make decision making complicated.
• It's not yet clear whether the decrease in deaths from prostate cancer is due to early detection and treatment based on PSA testing or due to other factors.

ARGUMENTS FOR & AGAINST PSA SCREENING

Arguments for screening — Experts in favor of prostate cancer screening cite the following arguments.

Results from a large European study of prostate cancer screening found that men who had PSA testing had a 20 percent lower chance of dying from prostate cancer after 13 years, compared to men who did not have prostate cancer screening.

A substantial number of men die from prostate cancer every year and many more suffer from the complications of advanced disease. For men with an aggressive prostate cancer, the best chance for curing it is by finding it at an early stage and then treating it with surgery or radiation. Studies have shown that men who have prostate cancer detected by PSA screening tend to have earlier-stage cancer than men who have a cancer detected by other means.

The five-year survival for men who have prostate cancer confined to the prostate gland (early stage) is nearly 100 percent; this drops to 30 percent for men whose cancer has spread to other areas of the body. However, many early-stage cancers are not aggressive, and the five-year survival will be nearly 100 percent even without any treatment.

The available screening tests are not perfect, but they are easy to perform and have fair accuracy.

Arguments against screening:

• Even though the European study found a benefit of prostate cancer screening, only about 1 man in every 1000 benefited from PSA testing after 13 years.
• Furthermore, 75 percent of men with an abnormal PSA who had a prostate biopsy did not have prostate cancer.
• A large American study did not find that prostate cancer screening reduced the chance of dying from prostate cancer

WHAT PEOPLE SHOULD KNOW ABOUT PSA SCREENING

• Screening doesn’t lower your risk of having prostate cancer; it increases the chance you’ll find out you have it.
• PSA testing can detect early-stage cancers that a DRE would miss.
• A “normal” PSA level of 4 ng/ml or below doesn’t guarantee that you are cancer-free; in about 15% of men with a PSA below 4 ng/ml, a biopsy will reveal prostate cancer.
• A high PSA level may prompt you to seek treatment, resulting in possible urinary and sexual side effects.
• Conditions other than cancer (BPH and prostatitis) can elevate your PSA level.

GENOMIC TESTS MAY HELP CLINICIANS

• One emerging tool that might help clinicians are new genomic tests
• Several currently available, including:
  • Genomic Health Oncotype DX prostate cancer test
  • Myriad Prolaris test

Hopefully genomic tests will help stratify patients with localized prostate cancer based on disease aggressiveness

US Task Force recommendation for breast cancer screening:

• Routine screening of average-risk women should begin at age 50, instead of age 40.
• Routine screening should end at age 74.
• Women should get screening mammograms every two years instead of every year.
• Breast self-exams have little value, based on findings from several large studies.

*American Cancer Society continues to recommend annual mammography screening for all healthy women beginning at age 40

BREAST CANCER SCREENING

• Regular breast cancer screening is important for all women, but even more so for those at higher risk.
  • If you are at higher risk of breast cancer, you may need to be screened earlier and more often than women at average risk. 
• A woman is considered at higher risk if she has one factor that greatly increases risk or several factors that together increase risk.
  •  Factors that greatly increase breast cancer risk include:
• A BRCA1 or BRCA2 gene mutation  
• A strong family history of breast cancer, such as a mother and/or sister diagnosed at age 45 or younger
  • A personal history of invasive breast cancer or ductal carcinoma in situation 
  • A personal history of lobular carcinoma in situ or atypical hyperplasia
  • Radiation treatment to the chest area before age 30
  • Li-Fraumeni syndrome, Cowden syndrome or Bannayan-Riley-Ruvalcaba syndrome (or a first-degree relative with one of these syndromes or family with a known p53 or PTEN gene mutation)
  • A greater than 20 percent lifetime risk of invasive breast cancer
• Breast cancer screening can help find breast cancer early, when the chances of survival are highest.
• Important for all women, no matter their level of risk.
• Women at higher risk may need breast cancer screening earlier and more often than other women.
• ·         Breast cancer screening is not recommended for most men.
• o    However, some men have a higher risk of breast cancer and should get screened.
• ·         Most women have an average risk of getting breast cancer.
• ·         Screening recommendations for women at average risk vary according to age

BREAST CANCER SCREENING/GENETIC TESTING PROS & CONS

PROS

• If you have a family member with a confirmed abnormal BRCA1, BRCA2, or PALB2 gene, and your test result is negative, your genetic counselor can tell you with greater certainty that you have the same relatively low risk of developing breast or ovarian cancer as people in the general population.
• Routine screening for breast cancer (self-exams, mammograms, doctor visits) will still be important for you, just as it is for all women.
• For ovarian cancer there are currently no widely accepted screening guidelines for women at average risk of developing the disease.
• Men with a negative test result know that they have the same extremely low risk of getting male breast cancer as men in the general population, and the same relatively low risk of prostate cancer.
• If your test result is positive, there are steps you can take to lower your risk of breast and/or ovarian cancer, or try to detect these cancers early if they should ever develop:
• Hormonal therapy medicine
• Tamoxifen, Evista, Aromasin - could reduce your risk of developing breast cancer
• Oral contraceptives - could reduce your risk of ovarian cancer.
• While data is not clear on the safety of oral contraceptives in people at high risk for breast cancer, some doctors do recommend them for people with abnormal genes.
• Depends on factors including which mutation you carry and how much breast or ovarian cancer is in your family.
  • More frequent clinical exams and breast screenings
• Every 6 months instead of once per year
• Ask for digital mammography (versus film screen mammography) and/or MRI in addition to mammography.
• Have regular pelvic exams and ultrasounds
• Possibly a blood test called CA-125, in an attempt to detect any early signs of ovarian cancer – this is what Angelina Jolie had
  • Preventive surgical removal of your breasts, ovaries, or both before cancer has an opportunity to form.
  • If you do develop cancer, you and your doctor will be able to make treatment decisions that take your genetic information into account.
• You can contribute to research that could eventually help to prevent or cure breast or ovarian cancer if you had genetic testing as part of a research program or if you participate in other clinical studies.
• Knowing that you carry an abnormal gene linked to breast cancer risk may prompt you and your family members to make lifestyle and family planning changes or other decisions that could help lower cancer risk.

CONS

• It's not yet clear exactly what you should or shouldn't do once you get your genetic test results.
• We still don't know the most effective ways to prevent breast or ovarian cancer.
• Removing the breasts and ovaries to lower cancer risk does not get rid of every breast- and ovary-related cell.
  • So even though surgery lowers your risk dramatically, it still does not entirely eliminate the risk.
    • Even after such surgery, a woman with an abnormal breast cancer gene must be monitored regularly.
    • These diseases may show up in nearby tissues and organs.
• Normal test results don't guarantee healthy genes.
• In some families, many women have had breast cancer, yet they all test normal for the known breast cancer mutations.
  • These families may have an inherited form of breast cancer caused by an abnormality or other gene that simply hasn't been identified yet.
  • If a woman tests negative for the mutations but the presence of a mutation has not been confirmed in a family member with cancer, she still is considered high-risk. In these situations, women need to be followed closely by their doctors
• Close monitoring with regular exams and screening does not always succeed in detecting breast and/or ovarian cancer early.
  • Some women end up being diagnosed with later-stage disease despite the best surveillance techniques.
• For some women, an abnormal test result can trigger anxiety, depression, or anger.
  • Even though the result doesn't mean that a woman will definitely get breast cancer, many women with an abnormal gene assume they will.
  • If you think knowing the information may be too hard for you emotionally, you might consider not having genetic testing until more is known about how to prevent and treat the disease.
• Genetic testing may not answer all your questions.
  • In families with an abnormal breast cancer gene, other factors that are not yet understood may contribute to high risk.

NEW GUIDELINES DON'T APPLY TO WOMEN AT HIGH RISK FOR BREAST CANCER. HOW OFTEN SHOULD WOMEN GET SCREENED?

• New guidelines aren't about women at high risk of breast cancer.
• American Cancer Society defines high-risk as women with a greater than 20% lifetime risk of breast cancer
  • This includes women with BRCA1 and BRCA2 gene mutations and women who have not been tested but have a parent, sibling, or child with a BRCA mutation
• ACS recommends that high-risk women have annual mammograms along with an MRI beginning at age 30 and continuing for as long as they are in good health.
• Women with a 15% to 20% lifetime risk for breast cancer are considered to have a moderately increased risk for the disease.
• ACS recommends that these women talk to their doctors about the benefits and risks of adding MRI to annual mammogram screening.

OVARIAN CANCER

US Task force recommends against screening for ovarian cancer.

Women with increased risk:

• A first degree relative (mother, sister, or daughter) with ovarian cancer.
• A personal history of breast cancer prior to age 40.
• A personal history of breast cancer diagnosed prior to age 50, and one or more close relatives diagnosed with breast or ovarian cancer at any age.
• Two or more close relatives diagnosed with breast cancer prior to age 50 or with ovarian cancer diagnosed at any age.
• Ashkenazi Jewish heritage and a personal history of breast cancer prior to age 50.
• Ashkenazi Jewish heritage and a first- or second-degree relative diagnosed with breast cancer prior to age 50 or with ovarian cancer at any age.

Should I ask my doctor for a CA 125 blood test to screen for ovarian cancer?

• Test Angelina Jolie used
• The cancer antigen 125 (CA 125) blood test isn't recommended for women with an average risk of ovarian cancer.

While women with ovarian cancer often have an elevated level of CA 125, an elevated CA 125 level doesn't always mean you have ovarian cancer. Some women with ovarian cancer never have an elevated CA 125 level. Many other conditions also can cause an elevated CA 125 level, including:

o   Diverticulitis

o   Endometriosis

o   Liver cirrhosis

o   Normal menstruation

o   Pelvic inflammatory disease

o   Pregnancy

o   Uterine fibroids

For these reasons, doctors don't recommend CA 125 testing in women with an average risk of ovarian cancer. Women with a high risk of ovarian cancer, such as those with mutations in the BRCA1 and BRCA2 genes, which increase the risk of breast and ovarian cancers, may consider periodic CA 125 testing. But even in these high-risk situations, there's some disagreement about the usefulness of the CA 125 test.

• Angelina Jolie Pitt (39 y.o.) underwent preventative surgery to remove her ovaries and fallopian tubes
• Decided to undergo surgery because she carries a gene that gave her a 50% risk of developing ovarian cancer
• She did not follow guidelines or protocols, but took her health in her own hands and spoke to experts in the field to make her decision
• In 2013, she elected to have a preventative double mastectomy after doctors detected a possible sign of early cancer
  • She had a mutation in the BRCA1 gene
  • BRCA1 gene – a gene that codes for tumor-suppressing proteins, which normally repair damaged DNA
  • When someone has a harmful mutation in that gene, it no longer allows the cell to repair itself, and then the cells can go awry and become cancerous
• Surgery to remove ovaries has the side effect of putting her into early menopause - comes with some health risks
• Removing the ovaries reduces her risk of ovarian cancer by 85 to 90%
  • Will also put her into menopause immediately
  • Jolie is only 39 - around a decade before the average woman enters menopause naturally
  • The average age for menopause in the United States is 51
• Breast and ovarian cancer are more prevalent among women with the harmful BRCA1 mutation
• National Cancer Institute:
  • About 12% of women develop breast cancer
  • Up to 65% of women with a BRCA1 mutation develop breast cancer by age 70
  • About 1.4% of women develop ovarian cancer
• About 39% of women with a BRCA1 mutation develop ovarian cancer by age 70
• Strong family history
  • Mother died of breast cancer at age 56
  • Aunt and grandmother also died of cancer
• After mastectomy, continued to get checked for ovarian cancer
  • Test - monitored levels of CA-125 - a protein that tends to increase in women with ovarian cancer
  • Test isn't very sensitive and shouldn't be used by itself to detect early ovarian cancer
  • Not a very good screening tool; better used to follow progress of treatment after diagnosis
  • Her doctors were also screening her levels of other inflammatory cells and proteins

Doctors said these markers were elevated and were possibly a sign of early cancer. After a series of body imaging tests, (CT, PET, and a tumor test) she learned she didn’t have ovarian cancer. Realizing it could still develop at any time, her doctors helped her decide that removing her ovaries and fallopian tubes was a good option for her. Still has an increased risk of cancer. A harmful BRCA1 mutation can increase the risk of other cancers, such as colon cancer and melanoma. The body also has ovarian-type cells in the abdomen, which can also become cancerous. There has been an increase in the number of women who requested preventative double mastectomies after AJP had mastectomy

KELLY OSBOURNE HAS CANCER GENE TOO

• Kelly Osbourne – 30 years old

  • Father - Ozzy Osbourne – famous rockstar
  • Mother - Sharon Osbourne, host of The Talk
• Diagnosed at age 50 with colon cancer which spread to her lymph nodes in 2002
• Was given only a 33% chance of survival 
• Mother tested for BRCA1 gene & found out she was a carrier
• Had double mastectomy
• Kelly tested for the BRCA gene & found she is a carrier
• Plans to take a similar course of action to Angelina Jolie

GENETIC TESTING FOR BRCA1 AND BRCA2

• Genetic testing gives people the chance to learn if their family history of breast cancer is due to an inherited gene mutation.

• Most women who get breast cancer do not have an inherited gene mutation.
  • 5 to 10 percent of breast cancers in the U.S. are linked to an inherited gene mutation
• BRCA1 and BRCA2 are the best-known genes linked to breast cancer.
• People who have a BRCA1 or BRCA2 mutation have a greatly increased risk of breast cancer and (for women) ovarian cancer.

WHO SHOULD CONSIDER TESTING FOR BRCA1 & BRCA2?

Although genetic testing for BRCA1 and BRCA2 is widely advertised, testing is only recommended for certain people, including those with:

• A known BRCA1/2 gene mutation in the family
• A personal history of breast cancer at age 45 or younger
• A personal history of breast cancer at age 50 or younger and a family member diagnosed with breast cancer at any age
• A personal history of triple negative breast cancer (breast cancer that isestrogen receptor-negative, progesterone receptor-negative andHER2/neu receptor-negative) diagnosed at age 60 or younger
• A personal history of ovarian cancer
• A personal or family history of male breast cancer
• Ashkenazi Jewish heritage and a personal or family history of breast or ovarian cancer
• A family member diagnosed with breast cancer at age 50 or younger
• A family member diagnosed with ovarian cancer at any age
• There is only a very small chance that your family carries a BRCA1/2 mutation if:
  • You or an immediate family member is the only person in your family with breast cancer
  • The breast cancers in your family all occurred at older ages
• In most cases, genetic testing is not recommended when there is a low chance of finding a mutation.
  • Most breast cancers are not due to a BRCA1/2 mutation.

WHAT’S WRONG WITH US TASK FORCE RECOMMENDATION

• It focuses on complications of treatment—incontinence & erectile dysfunction—but not on the value of screening and the amount it has saved the healthcare system
• Discusses population screening, but ignores African Americans, the effect of family history, and morbidity associated with prostate cancer
• No one on the task force has actually treated patients with prostate cancer
• Task force is made up of 16 volunteer members who are experts in prevention, evidence-based medicine, and primary care
• Their fields of practice and expertise include behavioral health, family medicine, geriatrics, internal medicine, pediatrics, obstetrics and gynecology, and nursing
• Prostate cancer mortality was on the decline before the task force issued its recommendation
• Task force failed to take into account evolving trends in the thinking of urologists regarding the PSA testing and prostate cancer treatment
• Recommendation has also affected policy - some commercial payers are denying coverage for PSA testing
  • Will affect patient outcomes in the long run
• Decisions are being made without proper input from the specialists who treat these diseases
• Prostate cancer mortality was on the decline before the task force issued its recommendation
• Since PSA testing, we have seen a 40% reduction in prostate cancer mortality in the United States

PSA TEST PROS

• PSA screening may help you detect prostate cancer early.

• Cancer is easier to treat and is more likely to be cured if it's diagnosed in the early stages of the disease

• PSA testing can be done with a simple, widely available blood test. 

• For some men, knowing is better than not knowing. Having the test can provide you with a certain amount of reassurance — either that you probably don't have prostate cancer or that you do have it and can now have it treated.

• The number of deaths from prostate cancer has gone down since PSA testing became available.

BREAST CANCER SCREENING 101

The American Cancer Society continues to recommend annual mammography screening for all healthy women beginning at age 40.

• Regular breast cancer screening is important for all women, but even more so for those at higher risk.
• If you are at higher risk of breast cancer, you may need to be screened earlier and more often than women at average risk. 
• Strong family history is important

OVARIAN CANCER SCREENING 101

• There is no simple and reliable way to screen for ovarian cancer in women who do not have any signs or symptoms.
• The CA 125 blood test isn't recommended for women with an average risk of ovarian cancer.
• The Pap test does not check for ovarian cancer. The only cancer the Pap test screens for is cervical cancer. Since there is no simple and reliable way to screen for any gynecologic cancer except for cervical cancer, it is especially important to recognize warning signs, and learn what you can do to reduce your risk.
• Here is what you can do:
• Pay attention to your body, and know what is normal for you.
• If you notice any changes in your body that are not normal for you and could be a sign of ovarian cancer, talk to your doctor about them.
• Ask your doctor if you should have a diagnostic test, like a rectovaginal pelvic exam, a transvaginal ultrasound, or a CA-125 blood test if—
• You have any unexplained signs or symptoms of ovarian cancer. These tests sometimes help find or rule out ovarian cancer.
• You have had breast, uterine, or colorectal (colon) cancer, or a close relative has had ovarian cancer.
• You have a genetic mutation (abnormality) in the BRCA1 or BRCA2 genes, or one associated with Lynch syndrome.

Ovarian Cancer Signs & Symptoms

• Vaginal bleeding or discharge from your vagina that is not normal for you.

• Pain in the pelvic or abdominal area (the area below your stomach and between your hip bones).
• Back pain.
• Bloating, which is when the area below your stomach swells or feels full.
• Feeling full quickly while eating.
• A change in your bathroom habits, such as having to pass urine very badly or very often, constipation, or diarrhea.

ANGELINA JOLIE

She did not follow guidelines or protocols, but took her health in her own hands and spoke to experts in the field to make her decision. She removed her ovaries to reduce her risk of ovarian cancer by 85 to 90%.

• Strong family history
• Mother died of breast cancer at age 56
• Aunt and grandmother also died of cancer

KELLY OSBOURNE

• Mother diagnosed diagnosed at age 50 with colon cancer which spread to her lymph nodes in 2002
• Tested for BRCA1 gene & found out she was a carrier
• Had double mastectomy