Cancer Screening and Prevention Knowing ... - Cleveland Clinic€¦ · Cancer Screening and Prevention Knowing Your Piece of the Oncology PIE Prevention, Identification, Education

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DOS Nurse Course 20121 DOS CME Course 20111 Oxtober 20101Confidential

Cancer Screening and Prevention

Knowing Your Piece of the Oncology PIE

Prevention, Identification, Education

Josette Snyder, RN, MSN, AOCNClinical Nurse Specialist

Taussig Cancer InstituteCleveland Clinic

© Cleveland Clinic 2012

• List risk factors for melanoma, thyroid, breast, colon, uterine, ovarian, lung, prostate, & hematologic cancers.

• Discuss patient education in relation to modifiable cancer risk factors and cancer prevention strategies.

• Describe signs and symptoms related to major cancer types.

• Discuss screening & diagnostic testing related to major cancer types.

Objectives

2 DOS Nurse Course 2012

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• 4 major NCD’s– Cancer

– Heart Disease

– Diabetes

– Lung disease

• 2 of 3 deaths are caused by NCD’s

9/19/11 United Nations Summit onNon-Communicable Diseases (NCD)


• Priority: early detection, screening and diagnosis

• Increase use availability of Hep B and HPV vaccines to prevent infection related cancers.

• Commitment to decrease avoidable cancer deaths by 25% by 2025

Union for International Cancer Control


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Prevention: Definition

• Disease prevention covers measures not only to prevent the occurrence of disease, such as risk factor reduction, but also to arrest its progress and reduce its consequences once established.

World Health Organization - 2011


• Tobacco use

• Obesity

• Unhealthy Diet

• Physical activity

• Alcohol use

• Infections

• Environmental pollution

• Occupational carcinogens

• Radiation

Common Modifiable Risk Factors


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Screening: Definition

• Screening is a process of identifying apparently healthy people who may be at increased risk of a disease or condition. They can then be offered information, further tests and appropriate treatment to reduce their risk and/or any complications arising from the disease or condition.


• Goals of screening:– Detect disease at a stage when treatment is most successful

– Should benefit the individual by increasing life expectancy and increasing quality of life.

– Rate of false positives should be low enough to prevent unnecessary additional testing.

– A large fraction of the population without the disease should not be harmed (low risk)

– Cost effective

• Decisions for individual screening are made in context of clinical picture

Principles of Screening Tests


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Melanoma: Introduction

• 3 main types of Skin Cancer– Basal Cell

– Squamous Cell

– Melanoma


Melanoma: Fast Facts

• Over one million new cases of skin cancer diagnosed each year, outnumbering the total number of other cancers combined

• 2000% increase in melanoma incidence since 1930 with one in 50 being affected

• Most common cancer killer of young women, more common than breast cancer in ages 29-34

• Early detection makes melanoma highly curable, but it is the least screened for cancer


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• Risk factors – non- melanoma– Sun exposure, natural or artificial (tanning booths/beds).

– Fair skin or light-colored eyes

– Actinic Keractosis

– Past treatment with radiation

– Weakened immune system (ie. Organ transplant)

– Exposure to arsenic

• Risk factors – melanoma– Fair skin or light-colored eyes

– Sun exposure, natural or artificial (tanning booths/beds)

– Blistering sunburn especially as child or teen

– An abundance of large and irregularly-shaped moles

– A family history of skin cancer

Melanoma: Risk Factors


• Avoid exposure to U/V rays

• Sunscreen use SPF 30 +– Both UVA and UVB protection

– Reapplication every 2 hours

• Seek shade– Sun rays most intense 10am & 4pm

• Protective clothing

• Avoid tanning beds/booths

• Dietary sources of vitamin D

• Regular skin self examination – “Check your birthday suit on your birthday”

Melanoma: Prevention


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• Regular skin self examination– More than 90% of melanomas that occur in the skin can be

recognized with the naked eye.

– Often a prolonged horizontal growth pattern before invading underlying dermis (potential for early detection)

– How to do a skin self exam, Body Mole Map–American Academy of Dermatology:

–www.aad.org

• Clinical skin examination– Include areas patient cannot see.

Melanoma: Screening


Melanoma: Signs & Symptoms

• A Asymmetry

• B Border

• C Color

• D Diameter

• E Evolving


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Melanoma

• Characteristics of melanoma

Skin Diseases & Conditions: Melanoma.Retrieved December 16, 2011 from www.skinipedia.org


• Biopsy

Melanoma: Diagnosis


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Thyroid

DOS Nurse Course 201217

Cleveland Clinic Thyroid Guide 2011

• 2-3 times more common in women than men

• 5th most common cancer diagnosed in women

• Peak incidence is around 49 years

• Three major types of thyroid cancer

–Differentiated:

–Papillary 80%

–Follicular 11%

–Hurthle cell 3%

–Medullary 4%

–Anaplastic 2% aggressive undifferentiated tumor

Thyroid Cancer: Fast Facts


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• Exposure to ionizing radiation (I131)– Particularly in children younger than age 10 at exposure

• Radiation to head & neck area

• Iodine deficiency

• Female

• Family history

Thyroid Cancer: Risk Factors


Thyroid Cancer: Prevention

• Potassium iodine (KI) protection–Radioactive emergency involving radioactive iodine

• TSH (Thyroid Stimulating Hormone)–Suppression may be used as treatment of thyroid

cancer

–Education for chronically suppressed TSH

–Ensure daily intake

–Calcium 1,200 mg/day

–Vitamin D 1,000 mg/day)


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• No routine screening recommendations

• Clinical exam – Inspection

– Palpation

• If nodule found– TSH (elevated)

– Ultrasound

• To determine if biopsy– Biopsy - FNA

Thyroid Cancer: Screening and Diagnosis


• Palpable Lump–Features that increase concern for malignancy:

– Firm

– Fixed to adjacent structures

– Rapidly growing

• Trouble swallowing

• Neck pain

• Cough

• Persistent hoarseness

Thyroid Cancer: Signs and Symptoms


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• 1 in 8 U.S. women will develop invasive breast cancer in her lifetime (1 in 1,000 for men)

• Incidence of breast cancer has decreased 1995-2005– 2% a year (in women 50 years and over)

– Believed to be due to reduced use of HRT

• For women in the U.S., breast cancer death rates are higher than those for any other cancer, besides lung cancer

• However; death rates have been decreasing since 1990

Breast Cancer: Fast Facts


Breast Cancer: Factors Associated with Increased Risk

• Age

• Early menarche– Before age 12

• Late child bearing– First live birth after age 30

• Nulliparous

• Immediate family member– Mother, sister, daughter

particularly pre-menopausal

• Hormone therapy– HRT at least 5 years, stronger

association with combination therapy, estrogen only mixed evidence

• Ionizing radiation– Depend on dose, location age

at exposure, highest risk at puberty

• Obesity– Post menopausal, not taking

HRT saw increased risk

• Major inheritance susceptibility– BRCA 1,2 positive

• Biopsy proven atypical hyperplasia

• Alcohol consumption


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Breast Cancer: Factors Associated with Decreased Risk

• Exercise (strenuous > 4 hours a week decreased incidence)

• Early pregnancy (full term pregnancy before age 20)

• Breast feeding


• Healthy diet

• Exercise 150 minutes or more per week

• Weight control

• No more than 1 drink per day

• No hormone replacement therapy (HRT)

Breast Canacer: High risk

• Medication – SERM’s, AI’s

• Prophylactic mastectomy, oophorectomy if indicated

• Breast exam every 6 months

• Annual mammogram and MRI

Breast Cancer: Prevention


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Breast Cancer: Screening Guidelines

• Mammograms (40-70 years old, benefit increases with age, as risk of breast cancer increases with age)– Benefit: early detection

– Younger 40 – 49, annual, decrease frequency with age

• Clinical Breast Exam– Ages 20-39 every 3 years

– After age 40 annual

• Self Breast Exam – Monthly self breast exam


• Palpable lump (usually non-mobile)

• Palpable change (thickening)

• Nipple discharge (usually bloody, spontaneous)

• Inverted nipple

• Indentation on the breast

• Skin changes (Peau d’orange, itchy/crusty nipple, redness, swelling)

* Many abnormalities are not palpable but are found on mammogram/ultrasound

Breast Cancer: Signs and Symptoms


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Breast Self Examination


• Variables important in palpating the breast correctly

–Patient position

–Breast boundaries

–Examination pattern

–Finger position, movement, and pressure

–Duration of the examination

Breast Cancer: Clinical Breast Exam


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Breast Cancer: Clinical Breast Exam

• Findings– Normal breasts are often lumpy

– Cancers classically are characterized as hard, fixed, and irregular

– Benign lumps are soft or cystic, movable, and regular

• However– Many cancers do not conform to the classic picture and

– Benign masses can mimic cancer.

• Because the characteristics of cancerous lumps overlap with those of non-cancerous lumps, clinicians rarely diagnose breast cancer with CBE

• However– Careful CBE can locate abnormalities. Further evaluation with

other testing is then required.


• Diagnostic tools:

–Screening Mammogram

–Diagnostic Mammogram

–Breast Ultrasound: (helpful in distinguishing a solid vs. fluid filled cyst)

–MRI: Dense breasts, known cancer to determine contralateral or multifocal disease, high risk

Breast Cancer: Diagnosis


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Breast Cancer: Diagnosis

• Mammogram categories: BIRAD scale

0 Incomplete, needs additional imaging

1 Negative mammogram

2 Benign mammogram

3 Probably benign (usually recommend 6 month follow-up with diagnostic mammogram and or ultrasound)

4 Suspicious needs biopsy (80% benign)

5 Highly suspicious (needs biopsy – 90% cancer)

6 Known cancer


• 3rd most common cancer in the US

• One in 20 lifetime risk among Americans

• Incidence increases in persons over age 40, mean age at diagnosis is 72

• Second leading cause of cancer death in US

Colon Cancer: Fast Facts


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Colon Cancer: Risk Factors

• Age

• African-American race

• A personal history of colorectal cancer or polyps

• Inflammatory bowel disease

• Inherited syndromes that increase colon cancer risk (FAP,HNPCC)

• Family history of colon cancer and colon polyps

• Low-fiber, high-fat diet

• A sedentary lifestyle

• Diabetes

• Obesity

• Smoking

• Alcohol

• Radiation therapy for cancer


Colon Cancer: Prevention

Decrease in colon cancer risk

• Physical activity

• Aspirin

• Post-menopausal HRT (combined hormone)

• Polyp removal

Unknown effect on colon cancer risk

• Non-steroidal anti-inflammatory drugs (NSAIDS)

• Diet modification (low fat, high fiber, fruits & vegetables)

• Vitamins

• Calcium


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Colon Cancer

• Progression

The colorectal adenoma-carcinoma sequence. From article: Colorectal cancer screening: prospects for molecular stool analysis: R.JustinDavies, Nature Reviews Cancer (March 2005) Retrieved December 15,2011 from www.nature.com/images


Beginning at age 50, both men and women should follow one of these testing schedules

Tests that find polyps and cancer

• Flexible sigmoidoscopy every 5 years, or

• Colonoscopy every 10 years, or

• Double-contrast barium enema every 5 years, or

• CT colonography (virtual colonoscopy) every 5 years

Tests that primarily find cancer

• Yearly fecal occult blood test (gFOBT), or

• Yearly fecal immunochemical test (FIT) every year, or

• Stool DNA test (sDNA), interval uncertain

Colon Cancer: Screening

ACS, 2010


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Colon Cancer: Signs and Symptoms

• Due to emphasis on screening, now often detected during screening procedures

• Weakness or fatigue

• Anemia

• Rectal bleeding

• Abdominal pain

• Change in bowel habits


• History and physical

• Colonoscopy and biopsy

• CEA blood test (CarcinoEmbryonic Antigen)

Colon Cancer: Diagnosis


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Cancer Screening and Prevention Knowing ... - Cleveland Clinic€¦ · Cancer Screening and Prevention Knowing Your Piece of the Oncology PIE Prevention, Identification, Education