Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Breast Cancer—BRCA1 AND 2 MUTATIONS Download Section PDF Listen +++ +++ Population ++ –Women age <60 y. +++ Recommendations ++ NCCN 2016 ++ –Who to screen: patients without cancer. Individual from a family with known deleterious BRCA1 and 2 gene mutation. Test only for the known mutation, not a full genetic evaluation. If strong family history (FH) but unable to test family member with cancer (not alive or unavailable to be tested) then do full genetic evaluation. A strong FH includes Two primary breast cancers in a single close relative (1st, 2nd, and 3rd degree relatives) Two breast cancer primaries on same side of family with at least one diagnosis occurring in a patient <50 y Ovarian cancer or male breast cancer at any age. –Who to screen: patients with breast, ovarian, pancreas, and prostate cancer. A known mutation in a cancer susceptibility gene within a family. Early age onset of breast CA (<50 y). Triple negative (ER-PR-, Her2-) breast cancer diagnosed in <60-y-old. An individual of Ashkenazi Jewish descent with breast, ovarian, or pancreatic cancer at any age. All women with ovarian cancer (epithelial and non-mucinous) at any age should be tested for BRCA1 and 2 mutations. +++ Comments ++ BRCA2 related breast cancer is more like sporadic BC with 75% of patients with hormonal receptor positivity and significant decrease in aggressive growth. Only 15% of BRCA2 patients will develop ovarian cancer with the average time of onset being in the mid-fifties. One in forty Ashkenazi Jewish men and women carry a deleterious BRCA1 or 2 gene (BRCA1 185del AG, 5382inse mutations, and BRCA2 6174delT mutation). Some experts believe all men and women of Ashkenazi descent should be tested for these 3 genes even with no personal or family history of malignancy. (N Engl J Med. 2016;374:454) + BREAST CANCER Download Section PDF Listen +++ +++ Population ++ –Women age 20–44 y. +++ Recommendations ++ ACS 2016 ++ –Inform women of benefits and limitations of breast self-examination (BSE). Teach women to report lumps or breast symptoms. –Do not routinely perform breast imaging for average-risk women. Women age 40–44 y should have the opportunity to begin annual screening if they desire. ++ Source ++ –http://www.cancer.org +++ Population ++ –Women age 40–49 y. +++ Recommendation ++ USPSTF 2012, AAFP 2013 ++ –Perform individualized assessment of breast CA risk; base screening decision on benefits and harms of screening as well as on a woman’s preferences and CA risk profile. (Ann Intern Med. 2012;156:635, 662) ++ Sources ++ –Ann Intern Med. 2012;156:609. –Ann Intern Med. 2014;160:864. –Am Fam Physician. 2013;87(4):274-278. ++ Table Graphic Jump Location | Download (.pdf) | Print CANCER, BREAST TABLE A: HARMS OF SCREENING MAMMOGRAPHY Harm (Ann Intern Med. 2016;164:256) Internal Validity Consistency Magnitude of Effects External Validity Treatment of insignificant CAs (overdiagnosis of indolent cancer) can result in breast deformity, lymphedema, thromboembolic events, and chemotherapy-induced toxicities. (Ann Intern Med. 2016;164:215) Good Good Approximately 20%–30% of breast CAs detected by screening mammograms represent overdiagnosis. (BMJ. 2009;339:2587) Oncotype DX (a predictive panel of 15 breast CA genes) can reduce the use of chemotherapy by 50% in node-negative hormone receptor-positive patients. (N Engl J Med. 2015;375:2005) Good Additional testing (false positives). Good Good Estimated to occur in 30% of women screened annually for 10 y, 7%–10% of whom will have biopsies. This creates anxiety and negative quality of life impact. (Ann Intern Med. 2009;151:738) (Ann Intern Med. 2011;155:481) (Br J Cancer. 2013;108:2205) Good False sense of security, delay in CA diagnosis (false negatives). (Ann Intern Med. 2016;164:268) Good Good Approximately 10%–30% of women with invasive CA will have negative mammogram results, especially if young with dense breasts or with lobular or high-grade CAs. (Radiology. 2005;235:775) All suspicious lumps should be biopsied even with negative mammogram. (Ann Intern Med. 2016;164:226) Good Radiation-induced mutation can cause breast CA, especially if exposed before age 30 y. Latency is more than 10 y, and the increased risk persists lifelong. (Ann Intern Med. 2016;164:205) Good Good In women beginning screening at age 40 y, benefits far outweigh risks of radiation-inducing breast CA. Women should avoid unnecessary CT scanning. (Br J Cancer. 2005;93:590) (Ann Intern Med. 2012;156:662) Good Source: NCI. 2010—http://www.cancer.gov (Ann Intern Med. 2016;164:205-304). +++ Comments ++ Harm and Benefit of Mammography Screening Benefits: Based on fair evidence, screening mammography in women age 40–70 y decreases breast CA mortality. The benefit is higher in older women (reduction in risk of death in women age 40–49 y = 15%–20%, 25%–30% in women age ≥50 y) but still remains controversial. (BMJ. 2014;348:366) (Ann Intern Med. 2009;151:727) Harms: Based on solid evidence, screening mammography may lead to potential harm by overdiagnosis (indolent tumors that are not life threatening) and unnecessary biopsies for benign disease. It is estimated that 20%–25% of diagnosed breast cancers are indolent and unlikely to be clinically significant. (CA Cancer J Clin. 2012;62:5) (Ann Intern Med. 2012;156:491) BSE does not improve breast CA mortality (Br J Cancer. 2003;88:1047) and increases the rate of false-positive biopsies. (J Natl Cancer Inst. 2002;94:1445) Twenty-five percent of breast CAs diagnosed before age 40 y are attributable to BRCA1 or 2 mutations. The sensitivity of annual screening of young (age 30–49 y) high-risk women with magnetic resonance imaging (MRI) and mammography is superior to either alone, but MRI is associated with a significant increase in false positives. (Lancet. 2005;365:1769) (Lancet Oncol. 2011;378:1804) Computer-aided detection in screening mammography appears to reduce overall accuracy (by increasing false-positive rate), although it is more sensitive in women age <50 y with dense breasts. (N Engl J Med. 2007;356:1399) Digital mammography and film screen mammography have equal accuracy in women 50- to 79-y-old, but digital is more accurate in women 40- to 49-y-old. (Ann Intern Med. 2011;155:493). Estimated 252,710 new cases of invasive breast cancer (63,400 with DCIS) are expected in 2017, with 40,600 expected deaths. (NCI. 2017) Future cancer screening: circulating tumor DNA mutations have been identified that correlate with specific underlying malignancy. Promising preliminary data exists for detection. (Nat Med. 2014;20:548) (J Clin Oncol. 2014;82:5) +++ Population ++ –Women age ≥50 y. +++ Recommendation ++ AAFP 2013 ++ –Perform mammography, with or without Clinical Breast Exam, every 1–2 y after counseling about potential risks and benefits. ++ Source ++ –Am Fam Physician. 2013;87(4):274-278. +++ Comments ++ Evidence is insufficient to recommend for or against routine CBE alone, or teaching or performing a routine BSE. Do not routinely screen women age >75 y. Breast MRI annually for BRCA1 and 2 mutation carriers or women with therapeutic chest radiation between ages 15 and 35. +++ Population ++ –Women age 45–54 y. +++ Recommendation ++ ACS 2015 ++ –Perform regular screening mammography for women with an average risk of breast cancer annually from age 45 to 54. ++ Sources ++ –CA Cancer J Clin. 2016;66:95. –JAMA. 2015;314:1599. –http://www.cancer.org +++ Comments ++ In 2016, 246,000 new invasive breast cancer cases per year were recorded 40,500 deaths. Mortality rates have declined by 1.9%/year from 1998 to 2012. Will these guidelines increase the risk of breast cancer deaths? It is estimated that 1.6 million breast biopsies are performed each year in the United States with the overwhelming majority having benign disease. (JAMA. 2015;313:1122) +++ Population ++ –Average risk women age ≥55 y. +++ Recommendations ++ ACS 2015 ++ –Women age ≥55 y should transition to biannual screening or have the opportunity to continue screening annually. –Women should continue screening mammography as long as their overall health is good and they have a life expectancy ≥10 y. –The ACS does not recommend clinical breast examination for breast cancer screening among average risk women at any age. +++ Comment ++ How do we classify average vs. high risk? BRCA1 and 2, mediastinal chest radiation for Hodgkin treatment in young females is easy but what about high BMI, lack of exercise, never pregnant, early menses, breast biopsy with atypical hyperplasia, dense breasts, breast cancer in the family, and much more—how many of these variables do you need to call a patient high risk? (JAMA. 2015;314:1615) (J Natl Cancer Inst. 2010;102:665) (J Natl Compr Netw. 2016;14:651) +++ Population ++ –High-risk patients. +++ Recommendations ++ ACS 2017 ++ –Women who are at high risk for breast cancer based on certain factors should get an MRI and a mammogram every year, typically starting at age 30. –High-risk includes: Lifetime risk of breast cancer 20%–25% or greater (according to risk assessment tools). Known BRCA1 and 2 mutation-positive women should begin MRI and mammogram screening at age 30 y or younger. Have a first-degree relative (parent, brother, sister, or child) with a BRCA1 or BRCA2 gene mutation, and have not had genetic testing themselves. Had radiation therapy to the chest when they were between the ages of 10 and 30 y. Have Li–Fraumeni syndrome, Cowden syndrome, or Bannayan–Riley–Ruvalcaba syndrome, or have first-degree relatives with one of these syndromes. ++ Sources ++ –CA Cancer J Clin. 2015;65:30. –N Engl J Med. 2015;372:2353. –J Clin Oncol. 2016;34:1882. –JAMA. 2012;307:1394. –J Clin Oncol. 2016;34:1840. +++ Population ++ –Women age 50–74 y. +++ Recommendations ++ USPSTF 2016 ++ –Biennial screening mammography for women age 50–74 y. –Breast Self-Exam teaching not recommended. –Inconclusive data for screening women age >75 y. –Decision to begin screening mammography before age 50 y should be individualized according to benefit vs. harm for each unique patient. (Ann Intern Med. 2009;151:727) (Ann Intern Med. 2012;156:609) (Ann Intern Med. 2016;164:279) –Insufficient evidence to assess benefits and harms of tomosynthesis, ultrasound, and MRI imaging for women with dense breasts. ++ Source ++ –https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/breast-cancer-screening1 +++ Populations ++ –Age 25–40 y (average risk). –Age >40 y (average risk). +++ Recommendations ++ NCCN 2018 ++ –Age 25–40 y: Clinical encounter every 1–3 y—breast awareness education in patients <40-y-old with average risk. –Age >40 y: Annual clinical encounter, mammogram yearly but MRI not recommended in average-risk patients. Women older than 80 or with limited life expectancy should not be screened. ++ Source ++ –www.nccn.org +++ Comments ++ Continued Controversy Over Screening The Canadian National Breast Screening study that began in 1980 found no survival benefit for mammography in 40- to 59-y-old women, but most experts in the United States consider the study to be flawed because of its design. (BMJ. 2014;348:g366) (N Engl J Med. 2014;370:1965) A recent meta-analysis (JAMA. 2014;311:1327) from Harvard found an overall reduction of 19% in breast cancer mortality (15% for women in their forties and 32% for women in their sixties). They were concerned about overdiagnosis and other potential harms of screening including false-positive findings and unnecessary biopsies. (N Engl J Med. 2016;375:1438) Recent trials have led to an increase in further screening studies based on the predicted individual risk of breast cancer occurrence. These also include a history of lobular carcinoma in situ, atypical hyperplasia, or history of breast CA (invasive and DCIS). (Ann Intern Med. 2016;165:700, 737) A woman with mediastinal radiation at age 10–30 y will have a 75-fold increased risk of breast CA at age 35 y vs. age-matched controls. Salpingo-oophorectomy will decrease risk of breast CA in BRCA1 and 2 carriers by 50% and decrease risk of ovarian CA by 90%–95%. +++ Population ++ –Lifetime risk of breast CA >20% based on personal and family history (utilize Gail model, BRCAPRO model, or Tyrer–Cuzick model) and genetic predisposition (BRCA1 or 2), PALB 2, CHEK 2 (http://www.cancer.gov/bcrisktool/). +++ Recommendations ++ NCCN 2018 ++ –Clinical encounter every 6–12 mo to begin when identified as being at increased risk; referral to genetic counseling if not already done. –Annual screening mammogram: to begin 10 y prior to the youngest family member but not prior to age 30 y. –Recommend annual breast MRI: to begin 10 y prior to youngest family member but not prior to age 25 y. +++ Population ++ –Patients who receive thoracic RT between ages 10 and 30 y. +++ Recommendations ++ NCCN 2018 ++ –For women younger than 25 y, recommend annual clinical encounter starting 10 y after radiation therapy. –For women 25 y or greater; recommend annual clinical encounter starting 10 y after radiation therapy; annual mammography to begin 10 y after RT but not prior to age 30 y; annual breast MRI to begin 10 y after RT but not prior to age 25 y. –www.nccn.org +++ Comments ++ Tamoxifen or raloxifene have not been studied as de novo chemo prevention in BRCA1 or 2 patients, but tamoxifen will decrease risk of contralateral breast CA by 50% in BRCA-mutated breast CA patients. (Int J Cancer. 2006;118:2281) Risk-reducing bilateral mastectomy in BRCA1 and 2 mutation carriers results in a 90% risk reduction in incidence of breast CA and a 90% rate of satisfaction among patients who underwent risk-reducing surgery at 10-y follow-up. (N Engl J Med. 2001;345:159) (JAMA. 2010;304:967) + BREAST CANCER Download Section PDF Listen +++ ++ Minimize Known Risk Factor Exposure ++ –NCCN 2018 If a woman is at high-risk secondary to a strong family history or very early onset of breast or ovarian cancer, genetic counseling should be offered. –Healthy Lifestyle: Breast cancer risks associated with combined estrogen/progesterone therapy ≥3–5 y duration of use Limit alcohol consumption to less than 1 drink per day (serving equals: 1 oz of liquor, 6 oz of wine, or 8 oz of beer) Exercise Weight control Breast-feeding –Risk-Reducing Agents: Discussion of relative and absolute risk reducing with tamoxifen, raloxifene, or aromatase inhibitors. Contraindications to tamoxifen or raloxifene: history of deep vein thrombosis, pulmonary embolus, thrombotic stroke, transient ischemic attack, or known inherited clotting trait. Contraindications to tamoxifen, raloxifene, and aromatase inhibitors: current pregnancy or pregnancy potential without effective nonhormonal method of contraception. Common and serious adverse effects of tamoxifen, raloxifene, or aromatase inhibitors with emphasis on age-dependent risks. –Risk-Reducing Surgery: Risk-reducing mastectomy should generally be considered only in women with a genetic mutation conferring a high risk for breast cancer, compelling family history, or possibly with prior thoracic RT at <30 y of age. While this approach has been previously considered for LCIS, the currently preferred approach is risk-reducing therapy. The value of risk-reducing mastectomy in women with deleterious mutations in other genes associated with a 2-fold or greater risk for breast cancer (based on large epidemiologic studies) in the absence of a compelling family history of breast cancer is unknown. +++ Comments ++ Hormone Replacement Therapy Approximately 26% increased incidence of invasive breast cancer when combination hormone replacement therapy (HRT) (estrogen and progesterone-Prempro) is used. Estrogen alone has mixed evidence, but is unlikely to increase risk of breast cancer significantly (decreases risk in African Americans). Ionizing Radiation to Chest and Mediastinum Increased risk begins approximately 10 y after exposure. Risk depends on dose and age at exposure (woman with radiation from age 15 to 30 y at highest risk). These patients often have received mediastinal radiation for Hodgkin Lymphoma. Obesity In Women’s Health Initiative (WHI), relative risk (RR) = 2.85 for breast CA for women >82.2 kg compared with women <58.7 kg only in postmenopausal women. Alcohol RR for intake of 4 alcoholic drinks/day is 1.32. RR increases approximately 7% for each drink per day. Family history—risk is doubled if a single first-degree relative develops breast cancer, and risk is increased 5-fold if 2 first-degree relative are diagnosed with breast cancer. (Breast CA Res Treat. 2012;133:1097) Factors of Unproven or Disproven Association Abortions. Environmental factors. Diet and vitamins. Underarm deodorant/antiperspirants—no evidence to support increased risk of breast cancer. (J Natl Cancer Inst. 2002;94:1578) Epidemiologic studies suggest vitamin D may decrease risk of breast cancer and breast cancer recurrence. Randomized controlled trials are needed. (N Engl J Med. 2011;364:1385) (Medicine. 2013;92:123) Active and passive cigarette smoking. Use of statin drugs. Use of low-dose daily aspirin. Population-based studies have shown reduction in breast CA risk with one 81-mg aspirin daily, but more data is needed. (J Clin Oncol. 2010;25:1467) (Lancet Oncol. 2012;13:518) Use of bisphosphonates for >1 y with 28% relative reduction in risk for postmenopausal breast CA. (J Clin Oncol. 2010;28:3577) (J Natl Cancer Inst. 2011;103:1752) New large study from Kaiser Permanente Northern California shows serum Vitamin D levels independently associated with breast cancer prognostic characteristics and patient prognosis. A randomized trial is needed. Underarm deodorants/antiperspirants—no evidence to support. (JAMA Oncol.2017;3:351-357) (J Natl Cancer Inst. 2002;94:1578) ++ Therapeutic Approaches to Reduce Breast Cancer Risk ++ –Tamoxifen (Postmenopausal and High-Risk Premenopausal Women) Treatment with tamoxifen for 5 y reduced breast CA risk by 40%–50%. USPSTF reemphasizes discussion with women at increased risk of breast cancer to strongly consider chemoprevention with selective estrogen receptor modulators (SERMs) or aromatase inhibitors (AIs in postmenopausal women only). (Ann Intern Med. 2013;159:698-718) Meta-analysis shows RR = 2.4 (95% confidence interval [CI], 1.5–4.0) for endometrial CA and 1.9 (95% CI, 1.4–2.6) for venous thromboembolic events. –Raloxifene (Postmenopausal Women) Similar effect as tamoxifen in reduction of invasive breast CA, but does not reduce the incidence of noninvasive tumors—studied only in postmenopausal women. Similar risks as tamoxifen for venous thrombosis, but no risk of endometrial CA or cataracts. (Lancet. 2013;381:1827) –Aromatase Inhibitors Anastrozole reduces the incidence of new primary breast CAs by 50% compared with tamoxifen; similar results have been reported with letrozole and exemestane treatment (Lancet. 2014;383:1041). Aromatase inhibitor use as a prevention of breast cancer will reduce the risk of developing breast cancer by 3%–5%. There is a 65% reduction in the risk of breast CA occurrence in postmenopausal women treated with exemestane for 5 y (chemoprevention). (N Engl J Med. 2011;364:2381) Harmful effects of aromatase inhibitors include decreased bone mineral density and increased risk of fracture, hot flashes, increased falls, decreased cognitive function, fibromyalgia, and carpal tunnel syndrome. There are no life-threatening side effects. Fracture rate for women being treated with anastrozole was 5.9% compared with 3.7% for those being treated with tamoxifen. The use of calcium, vitamin D, biphosphonates, and denosamab for patients at bone risk on aromatase inhibitors reduces the risk. (J Clin Oncol. 2012;30:3665) –Prophylactic Bilateral Mastectomy (High-Risk Women) Reduces risk of breast cancer as much as 90%. Approximately 6% of high-risk women undergoing bilateral mastectomies were dissatisfied with their decision after 10 y. Regrets about mastectomy were less common among women who opted not to have breast reconstruction. –Prophylactic Salpingo-oophorectomy among BRCA-Positive Women Breast CA incidence decreased as much as 50%. Nearly all women experience some sleep disturbances, mood changes, hot flashes, and bone demineralization, but the severity of these symptoms varies greatly. Salpingo-oophorectomy should be done in BRCA1 patients at 35 y of age and >40 y of age in BRCA2 patients. In patients who have uterus removed as well, it is safe to give estrogen replacement. (Eur J Cancer. 2016;52:138) –Exercise Exercising >120 min/wk results in average risk reduction of developing breast cancer by 30%–40%. There is also a 30% reduction in breast cancer recurrence in patients who have had breast CA. (Eur J Cancer. 2016;52:138) The effect may be greatest for premenopausal women of normal or low body weight. –Breast-Feeding The RR of breast CA is decreased 4.3% for every 12 mo of breast-feeding, in addition to 7% for each birth. –Pregnancy before Age 20 y Approximately 50% decrease in breast CA compared with nulliparous women or those who give birth after age 35 y. –Dense Breasts Women have increased risk of breast CA proportionate to breast density. Relative risk 1.79 for 50% density and 4.64 for women with >75% breast density. (Cancer Epidemiol Biomarkers Prev. 2006;15:1159) (Br J Cancer. 2011;104:871) No known interventional method to reduce breast density. Adding ultrasound to mammography will improve sensitivity and specificity and is more accurate than tomosynthesis without radiation exposure. (J Clin Oncol. 2016;34:1882, 1840) + CANCER, ORAL Download Section PDF Listen +++ ++ NCCN 2018 ++ –For women younger than 25 y, recommend annual clinical encounter starting 10 y after radiation therapy. –For women 25 y or greater, recommend annual clinical encounter starting 10 y after radiation therapy; annual mammography to begin 10 y after RT but not prior to age 30 y; annual breast MRI to begin 10 y after RT but not prior to age 25 y. –www.nccn.org + ORAL CANCER Download Section PDF Listen +++ +++ Population ++ –Asymptomatic persons. +++ Recommendation ++ AAFP 2015, USPSTF 2013 ++ –Insufficient evidence to recommend for or against routinely screening adults for oral asymptomatic CA. ++ Sources ++ –http://www.aafp.org/online/en/home/clinical/exam.html –http://www.ahrq.gov/clinic/uspstf/uspsoral.htm +++ Comment ++ –Primary risk factors for oral cancer are tobacco and alcohol use. Additional risk factors include male sex, older age, use of betel quid, ultraviolet light exposure, infection with Candida or bacterial flora, and a compromised immune system. Recently, sexually transmitted oral human papillomavirus infection has been recognized as an increasing risk factor for oropharyngeal cancer, another subset of head and neck cancer. + SKIN CANCER (MELANOMA) Download Section PDF Listen +++ +++ Recommendations ++ USPSTF 2016 ++ –Insufficient evidence to assess the balance of benefits and harms of visual skin examination by a clinician to screen for skin cancer in adults.a,b –Recommends counseling of children, adolescents, and young adults age 10–24 y who have fair skin to minimize exposure to ultraviolet radiation to reduce the risk of skin cancer. ++ Sources ++ –JAMA. 2016;316:429. –http://www.ahrq.gov/clinic/uspstf/uspsskca.htm +++ Comments ++ Benefits and Harms Benefits: Basal and squamous cell carcinoma are the most common types of cancer in the United States and represent the vast majority of all cases of skin cancer; however, they rarely result in death or substantial morbidity, whereas melanoma skin cancer has notably higher mortality rates. In 2016, an estimated 76,400 US men and women will develop melanoma and 10,100 will die from the disease. Harms: Potential for harm clearly exists, including a high rate of unnecessary biopsies, possibly resulting in cosmetic or, more rarely, functional adverse effects, and the risk of overdiagnosis and overtreatment. Direct evidence on the effectiveness of screening in reducing melanoma morbidity and mortality is limited to a single fair-quality ecologic study with important methodological limitations. Twenty-eight million people in the United States use UV indoor tanning salons, increasing risk of squamous, basal cell cancer, and malignant melanoma. (J Clin Oncol. 2012;30:1588) Clinical features of increased risk of melanoma (family history, multiple nevi previous melanoma) are linked to sites of subsequent malignant melanoma, which may be helpful in surveillance. (JAMA Dermatol. 2017;153:23) There are no guidelines for patients with familial syndromes (familial atypical mole and melanoma [FAM-M]), although systematic surveillance is warranted.c + ++ aClinicians should remain alert for skin lesions with malignant features when examining patients for other reasons, particularly patients with established risk factors. Risk factors for skin CA include evidence of melanocytic precursors (atypical moles), large numbers of common moles (>50), immunosuppression, any history of radiation, family or personal history of skin CA, substantial cumulative lifetime sun exposure, intermittent intense sun exposure or severe sunburns in childhood, freckles, poor tanning ability, and light skin, hair, and eye color. ++ bConsider educating patients with established risk factors for skin CA (see above) about signs and symptoms suggesting skin CA and the possible benefits of periodic self-examination. Alert at-risk patients to significance of asymmetry, border irregularity, color variability, diameter >6 mm, and evolving change in previous stable mole. All suspicious lesions should be biopsied (excisional or punch, not a shave biopsy) (Ann Intern Med. 2009;150:188) (USPSTF; ACS; COG). ++ cConsider dermatologic risk assessment if family history of melanoma in ≥2 blood relatives, presence of multiple atypical moles, or presence of numerous actinic keratoses. + SKIN CANCER Download Section PDF Listen +++ ++ Minimize Risk Factor Exposure ++ –Based on solid evidence, sun and UV radiation exposure are associated with an increased risk of squamous cell carcinoma (SCC) and basal cell carcinoma (BCC). ++ Therapeutic Approaches ++ –Sunscreen, protective clothing, limited time in the sun, avoiding blistering sunburn in adolescence and young adults. –Self-exam of skin, looking for changes that could possibly be cancer; higher risk patients need to be examined by dermatologist every 6–12 mo. ++ Source ++ –http://www.cancer.gov/types/skin/hp/skin-prevention-pdq + VITAMIN D DEFICIENCY Download Section PDF Listen +++ +++ Population ++ –Nonpregnant adults age 18 y or older. +++ Recommendations ++ USPSTF 2015, Endocrine Society 2011 ++ –Insufficient evidence to screen for vitamin D deficiency in asymptomatic adults. –Screen with serum 25-hydroxyvitamin D level in patients at riska for deficiency. ++ Sources ++ –J Clin Endocrinol Metab. 2011;96(7):1911-1930. –Ann Intern Med. 2015;162(2):133-140. + ++ aIndications for screening include rickets, osteomalacia, osteoporosis, CKD, hepatic failure, malabsorption syndromes, hyperparathyroidism, certain medications (anticonvulsants, glucocorticoids, AIDS drugs, antifungals, cholestyramine), African-American and Hispanic race, pregnancy and lactation, older adults with history of falls or nontraumatic fractures, BMI >30, and granulomatous diseases.