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Cancer Screening & Prevention – 65 & Beyond

By: the GAPNA Practice Committee

March 2014

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Background

Preventive medicine with behavior modification and health screening has allowed people to live longer (Bernstein 2010). Today’s health care provider practicing with the age 65 and older population is confronted with the challenge: when to stop cancer screening.

Cancer Screening

Colorectal Cancer

Colorectal cancer is both the third most common cancer and the third most common cause of cancer death in the United States (Bernstein 2010, Zoorob 2011). Incidence of colorectal cancer increases with age which must be balanced against life expectancy as adenomatous polyps are slow to progress to malignant lesions (Bernstein 2010, Zoorob 2011). Screening is not without adverse events and can include discomfort from the bowel prep, anesthesia reactions, colon perforation, and fatigue (Eckstrom 2012).

  • The United States Preventive Services Task Force (USPSTF), The American Cancer Society (ACS) and The American College of Obstetricians and Gynecologist (ACOG) recommends adults 50 years to 75, excluding those with specific inherited syndromes (Lynch syndrome or familial adenomatous polyposis) and those with inflammatory bowel disease. (Bernstein 2010, Smith 2014, USPSTF 2008)
    • Annual screening with high-sensitivity fecal occult blood test
    • Sigmoidoscopy every 5 years with high-sensitivity fecal occult blood test every 3 years
    • Colonoscopy every 10 years(Bernstein 2010, Smith 2014, USPSTF 2008)
  • The USPSTF recommends against routine screening for adults age 76-85 years and older, and against screening patient older than age 85. (USPSTF 2008)

Breast Cancer

Breast cancer is the most common cancer and the second most common cause of death from cancer in women in the United States. (Bernstein 2010, Smith 2014)

  • The ACS recommends clinical breast examination every 3 years and annually after age 40. (Smith 2014) The USPSTF has found insufficient evidence that clinical breast examination are beneficial in women over the age of 40 ( USPSTF 2009, Zooroob 2011) The ACOG recommends annual clinical breast exam for all women. (Bernstein 2010) The AGS recommends periodic clinical breast examinations (Bernstein 2010)
  • The ACS recommends that average-risk women should begin annual mammography at age 40. (Smith 2014) The USPSTF recommends biennial screening mammography in women aged 50 to 74 years. (USPSTF 2009) The USPSTF does not recommend mammography in women 75 years or older. (USPSTF 2009) The ACOG recommends mammography every 1-2 years in women age 40-49 and annually in women age 50 and older. (Bernstein 2010) The AGS recommends mammography every 1-2 years up to age 85 in women of average health and estimated life expectancy of 5 years or more. (Bernstein 2010) The AGS recommends screening mammography in women older than 85 years if life expectance is greater than 5 years. (Bernstein 2010)
  • Neither the ACS of the USPSTF recommend self breast examination. (Smith 2014, USPSTF 2009) The ACOG recommends breast self examination. (Bernstein 2010). The American Geriatrics Society (AGS) recommends periodic clinical breast exams, but does not specify frequency. (Bernstein 2010)

Cervical Cancer

Cervical cancer incidence and mortality have decreased since the introduction of the Papanicolaou (Pap) test or smear. (Smith 2014) The largest risk factor for the development of cervical cancer is infection with certain strains of the human papilloma virus (HPV). (Berstein 2010)

  • The USPSTF and the ACS recommends screening for cervical cancer should begin at age 21. (Bernstein 2010) The USPSTF and the ACS also recommends after initiation of intercourse that a woman should have a pap smear every 3 years even if under the age of 21. (Bernstein 2010) The ACOG does not recommend a screening pap smear under the age of 21 (Bernstein 2010) Women aged 21 to 65 years should receive a Pap smear every 3 years. (Smith 2014, Campos-Outcalt  2012) The ACOG recommends every 2 year pap smears from age 21 to 30 years every 2 years. Age 30 women with average risk with 3 consecutive normal Pap smears should receive a Pap smear every 2 to 3 years or may elect to screen with both Pap smears and HPV testing. Those with both normal cytology and a negative HPV should be screened no more than every 3 years (Bernstein 2010) The American Geriatric Society (AGS) recommend pap screening every 1-3 years until age 70. Any older woman who has never had a pap smear may be screened with 2 negative pap smears 1 year apart. (Bernstein 2010)
  •  The USPSTF and the ACS state that women aged 30 to  65 years should be screened every 5 years with the combination of HPV testing and cytology. (Smith 2014, Campo-Outcalt 2012) The ACS states that it is also acceptable to be screened every 3 years with only cytology. (Smith 2014) ACOG recommends at age 30, women of average risk with 3 consecutive normal pap smears can space pap smears to every 2-3 years. (Bernstein 2010) Women may elect to screen with both pap smears and HPV testing. Women who have undergone a total hysterectomy who have never had CIN 2 or 3 should discontinue pap screening. Those with a history CIN 2 or 3 should continue annual vaginal cytology screening until they have had 3 consecutive negative tests. (Bernstein 2010)
  • The USPSTF recommends against routinely screening women older than age 65 if they have had adequate recent screening with normal pap smears and are not ar high risk for cervical cancer. (Bernstein 2010) The ACS recommends at age 70, women with 3 consecutive normal pap smears in the last 10 years may stop getting pap smears. Women with risk factors including a history of cervical cancer should continue being screened. (Bernstein 2010) AGOG recommends that physicians determine on an individual basis when an older woman can stop having cervical cancer screening based on medical history and the physician’s ability to monitor the patient in the future. Berstein 2010)   ACS  recommends assessing risk factors, such as the patients life expectancy, ability to undergo treatment if cancer is detected and ability to coopertie with and tolerate the pap smear procedure. (Berstein 2010)

Ovarian Cancer

Ovarian cancer is the most deadly cancer of the female reproductive tract and the fifth most common cause of cancer death in women.(Bernstein 2010)

  • The USPSTF , the ACS and ACOG recommend against routine screening for ovarian cancer using eith transvaginal ultrasound or CA-125.
  •  The USPSTF and the ACS have no recommendation for or against bimanual pelvic exam. (Berstein 2010) ACOG recommends that physicians discuss with patients symptoms such as increase in abdominal size, bloating, fatigue, pain, indigestion, decreased oral intake, urinary frequency, constipation, or unexplained weight loss. ACOG recommends annual pelvic exams for palpation for adnexal masses on bimanual exam. (Berstein 2010)

Endometrial Cancer

Endometrial carcinoma is the most common gynecologic malignancy and the fourth most common malignancy in older women. (Berstein 2010)

  • The USPSTF, ACS,  and AGOG recommends against routine screening for ovarian cancer using transvaginal ultrasound or CA-125. (Berstein 2010)
  • The USPSTF and ACS have no recommendation for bimanual pelvic exam. AGOG recommends that physicians discuss symptoms such as increase in abdominal girth, bloating, fatigue, pain, indigestion, decreased oral intake, urinary frequency, constipation, or unexplained weight loss. (Berstein 2010) Annual pelvic exams are recommended for palpation of adnexal masses on bimanual exam. (Bernstein 2010)

Prostate Cancer

Prostate Cancer accounts for one third of new cancer cases in men, but only 10% of male cancer deaths. (Zoorob 2011) Prostate cancer screening has not been shown to  decrease prostate cancer mortality. (Ilic 2013)

  • The USPSTF has never endorsed use of the prostate specific antigen (PSA) for men of all ages. (Campos-Outcalt 2013)
  • The ACS states that prostate cancer screening should not occur without an informed decision-making process. Men at average risk should receive information regarding the screening beginning at age 50. (Smith 2014) African American men and men with a father or brother diagnosed with prostate cancer before age 65, should receive screening information beginning at age 65. (Smith 2014) Men with multiple family members diagnosed with prostate cancer prior to age 65, should receive screening information beginning at age 40. (Smith 2014) Asymptomatic men who have less than a 10 year life expectancy based on age and health status should not be offered prostate cancer screening (Smith 2014)
  • ACS prostate cancer screening after shared and informed decision-making includes: serum PSA with or without digital rectal examination (DRE) (Smith 2014) For men with whose PSA is less than 2.5 ng/ml screening intervals should be every 2 years. (Smith 2014) A PSA level of 4.0 or higher should be referred for further evaluation or biopsy. (Smith 2014)
  • The American College of Preventive Medicine (ACPM) concludes that there is insufficient evidence to recommend routine population screening with DRE or PSA.(Qaseem 2013) For African American men and those with a family history of prostate cancer may benefit from earlier screening beginning at age 45. (Qaseem 2013) Men with 2 or more first degree relatives with prostate cancer before age 65 should be screened at age 40. (Qaseem 2013)
  • The American Urology Association (AUA) recommends that men who wish to be screened for prostate cancer should have both a PSA test and a DRE. (Qaseem 2013) This screening should be offered to asymptomatic men 40 and have an estimated life expectancy of more than 10 years. (Qaseem 2013)

References

  • Bernstein, R., Dejoseph, D., and Buchanan, E. ( 2010) Whento stop screening: a review of brest, gynecologic, and colorectal cancer screening in women over age 65 Care Management Journals 11(1) 48-57. doi: 10.1891/1521-0987.11.1.48
  • Campos-Outcalt, D. (2012) The latest recommendations for the ASPSTF. The Journal of Family Practice 61(5) 278-282
  • Campos-Outcalt, D. (2013) The latest recommendations from the USPSTF. The Journal of Family Practice 62(5) 249-252
  • Ilic, D., Neuberger, M., Djulbegovic, M., and Dahm, P. (2013) Screening for prostate cancer (review). The Cochrane Library 2013 1 1-51
  • U. S. Preventive Services Task Force (2009) Screening for breast cancer: U.S. Preventive Services Task Force Recommendation Statement. Annals of Internal Medicine 151(10) 716-726
  • U. S. Preventive Services Task Force (2008) Screening for colorectal cancer: U. S. preventive services task force recommendation statement. Annals of Internal Medicine 149(9) 627-637
  • Zoorob, R., Kihlberg, C., and Taylor, S. (2011) Aging and disease prevention. Clinics in Geriatric Medicine 27(4) 523-539

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