A 55-year-old Caucasian man comes to your clinic for an annual examination. He has no pertinent medical history and feels well. His family history is positive for dyslipidemia in his father. His review of systems and physical examination is unremarkable. He is interested in having all the recommended cancer screening tests suggested for someone of his age.
1. Which cancers should you screen for?
2. What tests will you use to screen?
He should be screened for colorectal cancer. He is at an average risk for colorectal cancer given his age (≥50) and the absence of other risk factors. He has no risk factors or symptoms of prostate cancer and there is no indication to perform a PSA. He has no risk factors for lung cancer.
To screen for colorectal cancer on this average-risk patient, there are 3 options: serial fecal occult blood testing (FOBT), flexible sigmoidoscopy, and optical colonoscopy. Given the similar performance, lower cost, minimal preparation, and minimal potential harm, FOBT is preferable. You advise the patient to collect 2 samples from 3 consecutive stools at home. If positive for blood, he will need to have an optical colonoscopy.
Breast cancer is the second leading cause of cancer-related death among women in the United States. Risk factors include older age, family history of breast cancer, early menarche, older age at the time of first childbirth, and a history of breast biopsy. A family history might suggest the presence of BRCA1 or BRCA2 mutations. Women with possible BRCA mutations should be referred for counseling.
Screening mammography reduces breast cancer mortality in women 50 to 70 years of age. There is ongoing debate about the benefit for women of ages 40 to 49.
The American College of Physicians (ACP) released guidelines on screening women in 2007 and they can be summarized as follows: clinicians should perform individualized assessment of risk factors for breast cancer periodically (1–2 years) to help guide the decision about screening. Women should be informed about potential benefits and harms related to screening mammography. Benefits and harms of screening, a woman's preferences, and breast cancer risk profile should guide the decision to screen.
The U.S. Preventive Service Task Force (USPSTF) also recommends an individualized decision based on a patient's values and the benefits and harms of screening in women younger than 50. The USPSTF recommends biennial screening mammography for women 50 to 74 years old. They state there is insufficient evidence to assess the benefits and harms of screening women ≥75 years old. The USPSTF recommends against the teaching of breast self-examination (BSE), and notes that there is insufficient evidence to assess the benefits or harms using digital mammography or breast MRI instead of film mammography.