1 . Which of the following represents the standard criterion for the effectiveness of cancer screening?
| A) | | Increase in the 5-year survival rate |
| B) | | Increase in the number of cancers detected |
| C) | | Decrease in the cause-specific mortality rate |
| D) | | Decrease in the percentage of cancers diagnosed as stage IV |
ISSUES IN CANCER SCREENING
Early detection and treatment offer potential benefits of
reduced morbidity and longer survival; however, these benefits alone do not define a cancer
screening test as effective. Rather, the standard criterion for effective screening is
evidence of a decrease in cause-specific mortality in randomized controlled trials [9]. This definition of efficacy is often
misunderstood by the general public as well as by clinicians, who may consider screening to be
effective if it increases early detection and improves survival. This misinterpretation was
demonstrated in a study of clinicians' understanding of screening in which more than 300
primary care physicians were presented with scenarios about the effect of two hypothetical
screening tests. In that study, significantly more physicians said they would recommend a
screening test associated with an increase in five-year survival from 68% to 99% compared with
a screening test associated with a decrease in cancer mortality from 2 to 1.6 per 1,000
persons (69% vs. 23%) [10]. Nearly half (47%)
of the physicians said that detecting more cases of cancer in a screened population than an
unscreened one was proof that screening saves lives.
2 . A meta-analysis showed that which of the following was the barrier to screening most often cited by patients?
| A) | | No health insurance |
| B) | | Attitudes toward screening |
| C) | | Lack of trust in health care |
| D) | | Lack of healthcare professional recommendation |
ISSUES IN CANCER SCREENING
Patient-related factors have included race/ethnicity,
attitude toward screening, obesity, education level, income level, level of trust, access
to health care, and availability of health insurance [7,12,14,20,21,22,23,24]. Lack of
healthcare professional recommendation has also been a barrier noted by patients, with one
meta-analysis showing that it was the most often cited barrier [25,26]. This finding highlights the importance of clinicians enhancing their
adherence to guidelines and recommending appropriate screening to their patients.
3 . Of the following, overdiagnosis has been most often associated with
| A) | | skin cancer. |
| B) | | lung cancer. |
| C) | | cervical cancer. |
| D) | | colorectal cancer. |
ISSUES IN CANCER SCREENING
Overdiagnosis has been associated most often with breast,
prostate, and lung cancer. There is little evidence of overdiagnosis with screening for
either cervical or colorectal cancer (with conventional methods), because the rate of
diagnosis of both cancers is decreasing [52].
4 . Which of the following recommendations adheres to most screening guidelines for a 30-year-old asymptomatic woman at average risk for breast cancer?
| A) | | No screening |
| B) | | Mammography every two years |
| C) | | Breast self-examination every month |
| D) | | Clinical breast examination every one to three years |
RECOMMENDATIONS FOR BREAST CANCER SCREENING FOR AVERAGE-RISK WOMEN
| Organization (Year) | Screening Recommendations |
|---|
| Imaging | Clinical Breast Exam | Self-Exam |
|---|
| U.S. Preventive Services Task Force (2016) |
| Age 50 to 74 years: Biennial mammography | | Age ≥75 years: Evidence is insufficient to assess benefits and
harms |
| Not addressed | Awareness of breast changes; discuss changes with physician |
| American College of Physicians (2019) |
| Age 40 to 49 years: Individualized assessment of risk for discussion of
benefits and harms of screening mammography, as well as woman's
preferences | | Age 50 to 74 years: Offer biennial mammography | | Age 75 and older or life expectancy less than 10 years: Do not
screen. |
| Do not use | Not addressed |
| American Cancer Society (2015) |
| Age 45 to 54 years: Annual mammography (40 to 44 years, optional) | | Age 55 years and older: Biennial screening (annual optional) | | Less than 10 year life expectancy: No screening |
| Not recommended | Not recommended |
| National Comprehensive Cancer Network (2022) | Age ≥40 years: Annual mammography |
Age ≥25 years but <40 years: Every 1 to 3 years
Age ≥40 years: Annually
| Breast awareness |
| American College of Obstetrics and Gynecology (2017, 2019 guidance
statement) |
| Age 40 to 49 years: Individualized assessment of risk; discussion of
benefits/harms of screening mammography and woman's preferences. | | Age 50 to 74 years: Biennial screening | | Age 75 years and older: No screening in patient with less than 10-year life
expectancy |
| Do not use | Not addressed |
| Society of Breast Imaging/American College of Radiology (2010) | Age ≥40 years: Annual mammography; end screening when life expectancy is <5 to
7 years | Not addressed | Not addressed |
5 . Which of the following breast cancer screening recommendations is guideline consistent for an asymptomatic woman 54 years of age with average risk?
| A) | | Mammography alone |
| B) | | Mammography with MRI |
| C) | | Mammography with ultrasound |
| D) | | Mammography with ultrasound and MRI |
The National Comprehensive Cancer Network (NCCN) and the
Society of Breast Imaging/American College of Radiology (SBI/ACR) recommend screening
mammography beginning at 40 years of age for women with average risk for the disease and
no symptoms [56,58]. The American College of Physicians (ACP)
and the American College of Obstetrics and Gynecology (ACOG) determined that clinicians
should discuss the potential benefits and harms of screening mammography with women 40 to
49 years of age and base decisions about screening on these benefits and harms, as well as
on a woman's preferences and breast cancer risk profile [57,60]. Physicians should
order biennial mammography screening if an informed woman requests it.
6 . The breast cancer screening method recommended in all guidelines is
| A) | | ultrasound. |
| B) | | digital mammography. |
| C) | | breast self-examination. |
| D) | | clinical breast examination. |
Digital mammography has nearly entirely replaced film
mammography in the United States and is the screening method recommended in all guidelines
[56,57,58,59,60,61]. Meta-analyses of
large randomized trials have shown that the detection rate is slightly higher for digital
mammography compared with film mammography. However, data on the benefit of digital
mammography have been conflicting. In one meta-analysis, the higher detection rate was
found primarily among women 60 years of age and older, whereas in another, the detection
rate was higher among women younger than 50 years of age [66,67]. The NCCN notes that digital mammography appears to most benefit young
women and women with dense breasts [56].
7 . A woman is 38 years of age and has a five-year risk of breast cancer of 1.8% according to the modified Gail model. Which of the following screening recommendations is guideline consistent?
| A) | | Mammography alone every two years |
| B) | | Mammography and MRI every year |
| C) | | Mammography and clinical breast examination every year |
| D) | | Mammography every year and clinical breast examination every 6 to 12 months |
BREAST CANCER SCREENING OR SURVEILLANCE ACCORDING TO HIGH-RISK FACTORS
| Risk Factor | Recommendation for Screening |
|---|
| NCCN | SBI/ACR |
|---|
| Age 35 years or older and five-year risk of invasive breast cancer of 1.7% or
more according to the modified Gail model |
| Annual digital mammography plus clinical breast examination every 6 to
12 months | | Breast awareness |
| — |
| Lifetime risk of more than 20% according to risk models that rely primarily
on family history |
| Annual digital mammography plus clinical breast examination every 6 to
12 months beginning 10 years before youngest affected family member (but not
younger than 30 years of age) and annual breast MRI beginning at same
time. | | Referral to genetic counseling | | Breast awareness |
| Annual mammography and MRI by 30 years of age but not before 25 years of age)
or 10 years before age of youngest affected family member |
| Radiation therapy (RT) to the chest at a younger age (10 to 30 years) |
| Women <25 years of age: Annual clinical breast examination beginning
8 years after RT | | Women ≥25 years of age: Annual digital mammography plus clinical breast
examination every 6 to 12 months beginning 8 years after RT but not prior to
30 years of age and recommended annual breast MRI 8 years after RT but not
prior to 25 years of age | | Breast awareness |
| Annual mammography and MRI beginning 8 years after RT; mammography before 25
years of age is not recommended |
| Lifetime risk of more than 20% based on history of lobular carcinoma in situ
or ADH/ALH |
| Annual digital mammography plus clinical breast examination every 6 to
12 months beginning at the time of diagnosis but not less than 30 years of
age | | Consider annual MRI | | Breast awareness |
| Annual mammography from time of diagnosis; annual MRI may also be
considered |
| Personal history of breast cancer | Annual digital mammography and history and physical examination every 4 to 6
months for 5 years, then every 12 months | Annual mammography from time of diagnosis; either annual MRI or ultrasound
may be considered |
| Suggested or known hereditary breast and ovarian cancer syndrome
(BRCA1 or BRCA2 mutations) |
| Women: Annual MRI with contrast (preferred) or mammography (if MRI
unavailable) at 25 to 29 years of age—may individualize the starting age based
on family history if breast cancer diagnosis under 30 years of age is
present | | Annual mammography and MRI with contrast at 30 to 75 years of
age | | Consider screening on an individual basis after 75 years of age | | Clinical breast examination every 6 to 12 months starting at 25 years of
age | | Breast awareness starting at 18 years of age |
| Annual mammography and MRI beginning at 30 years of age but not before 25
years of age |
| Men: Clinical breast examination every 12 months starting at 35 years of
age | | Breast self-exam starting at 35 years of age |
| — |
| Peutz-Jeghers syndrome | Annual mammography and MRI plus clinical breast examination every 6 months
beginning around 25 years of age | — |
| Lynch syndrome | Optimal screening strategy uncertain | — |
| Cowden syndrome |
| Annual mammography and breast MRI starting at 30 to 35 years of age or 5
to 10 years before the earliest known breast cancer in the family (whichever
comes first) | | Clinical breast examination every 6 to 12 months starting at 25 years of
age or 5 to 10 years before the earliest known breast cancer in the family
(whichever comes first) | | Breast awareness starting at 18 years of age |
| — |
| Li-Fraumeni syndrome |
| Annual breast MRI with contrast (preferred) or mammography and starting
at 20 to 29 years of age (or individualized based on earliest age of onset in
family) | | Annual mammography and breast MRI at 30 to 75 years of age | | Clinical breast examination every 6 to 12 months starting at 20 to 25
years of age or 5 to 10 years before the earliest known breast cancer in the
family if before 20 years (whichever comes first) | | Breast awareness starting at 18 years of age |
| — |
| ADH = atypical ductal hyperplasia, ALH =
atypical lobular hyperplasia, NCCN = National Comprehensive Cancer Network,
SBI/ACR = Society of Breast Imaging/American College of Radiology. |
8 . According to a meta-analysis, screening mammography leads to the greatest reduction in breast cancer-related mortality among which of the following age-groups?
| A) | | 39 to 49 years |
| B) | | 50 to 59 years |
| C) | | 60 to 69 years |
| D) | | 70 to 80 years |
A meta-analysis done as part of the USPSTF literature
review showed that reductions in mortality differ among age-groups. Screening with
mammography reduced breast cancer-related mortality by 15% for women 39 to 49 years of
age, by 14% for women 50 to 59 years of age, and by 32% for women 60 to 69 years of age
[95]. Investigators conducting a
Cochrane review also found that screening was associated with a significant reduction in
mortality but that screening had no effect on mortality when only trials with adequate
randomization were considered [96]. These
authors estimated that screening reduced mortality by approximately 15%, but with an
absolute reduction of about 0.05% per year for a woman of average risk [96]. The Cochrane review excluded
observational studies, which have shown a positive effect of mammography [70].
9 . Of the following, performance of a biopsy based on the findings of screening mammography is most likely for a woman who is
| A) | | 48 years of age. |
| B) | | 52 years of age. |
| C) | | 65 years of age. |
| D) | | 72 years of age. |
Mammographic findings also commonly lead to additional
procedures. Additional imaging is done in 56.3 to 84.3 women per 1,000 screened, with the
highest rate among women 40 to 49 years of age [95]. The rate of biopsy is lower, ranging from 12.2 per 1,000 screened for
women 70 to 79 years of age to 9.3 per 1,000 screened for women 40 to 49 years of age. An
estimated 47 women per 1,000 screened 40 to 49 years of age will have additional imaging
to diagnose one case of invasive breast cancer, and an estimated five women per 1,000
screened of the same age will have a biopsy to diagnose one case of invasive breast cancer
[95]. These numbers are lower for other
age-groups, ranging from eight to 22 per 1,000 screened for additional imaging and 1.5 to
three per 1,000 screened for biopsy [95].
10 . Which of the following cervical cancer screening recommendations is guideline consistent for an asymptomatic woman who is 25 years of age?
| A) | | No screening |
| B) | | Screening with cytology alone every year |
| C) | | Screening with cytology alone every three years |
| D) | | Screening with cytology and HPV testing every three years |
RECOMMENDATIONS FOR CERVICAL CANCER SCREENING FOR AVERAGE-RISK WOMEN
| Screening Factor | USPSTF | ACS/ASCCP/ASCP |
|---|
| Starting age | 21 years | 21 years |
| Ending age | 65 years if prior screenings are negative within past 10
yearsa | 65 years if prior screenings are negative within past 10 yearsa and if there has
been no history of CIN2+ within the past 20 years |
| Screening method |
| Age 21 to 29 years: Cytology (Pap test) alone | | Age 30 to 65 years: Cytology alone, hrHPV testing alone, or cytology plus
hrHPV testing |
|
| Age 21 to 29 years: Cytology (Pap test) alone | | Age 30 to 65 years: Cytology plus HPV testing (preferred) or cytology
alone |
|
| Screening interval |
| Age 21 to 29 years: Every 3 years | | Age 30 to 65 years: Every 3 years for cytology alone; every 5 years for
hrHPV testing alone; every 5 years for cytology plus hrHPV testing |
|
| Age 21 to 29 years: Every 3 years | | Age 30 to 65 years: Every 3 years for cytology alone; every 5 years for
cytology plus HPV testing |
|
| ACS/ASCCP/ASCP = American Cancer Society/American Society for Colposcopy and
Cervical Pathology/American Society for Clinical Pathology, CIN2+ = cervical
intraepithelial neoplasia of grade 2 or higher, hrHPV = high risk human
papillomavirus, Pap = Papanicolaou, USPSTF = U.S. Preventive Services Task
Force. | | aAdequate prior screening is defined as three
consecutive negative cytology results (or two consecutive negative co-testing
results) within the past 10 years, with the most recent test occurring within the
past 5 years. |
|
11 . The preferred cervical cancer screening recommendation for an asymptomatic woman who is 45 years of age is
| A) | | cytology alone every 3 years. |
| B) | | cytology alone every 1 to 2 years. |
| C) | | cytology and HPV testing every 3 years. |
| D) | | cytology and hrHPV testing every 5 years. |
RECOMMENDATIONS FOR CERVICAL CANCER SCREENING FOR AVERAGE-RISK WOMEN
| Screening Factor | USPSTF | ACS/ASCCP/ASCP |
|---|
| Starting age | 21 years | 21 years |
| Ending age | 65 years if prior screenings are negative within past 10
yearsa | 65 years if prior screenings are negative within past 10 yearsa and if there has
been no history of CIN2+ within the past 20 years |
| Screening method |
| Age 21 to 29 years: Cytology (Pap test) alone | | Age 30 to 65 years: Cytology alone, hrHPV testing alone, or cytology plus
hrHPV testing |
|
| Age 21 to 29 years: Cytology (Pap test) alone | | Age 30 to 65 years: Cytology plus HPV testing (preferred) or cytology
alone |
|
| Screening interval |
| Age 21 to 29 years: Every 3 years | | Age 30 to 65 years: Every 3 years for cytology alone; every 5 years for
hrHPV testing alone; every 5 years for cytology plus hrHPV testing |
|
| Age 21 to 29 years: Every 3 years | | Age 30 to 65 years: Every 3 years for cytology alone; every 5 years for
cytology plus HPV testing |
|
| ACS/ASCCP/ASCP = American Cancer Society/American Society for Colposcopy and
Cervical Pathology/American Society for Clinical Pathology, CIN2+ = cervical
intraepithelial neoplasia of grade 2 or higher, hrHPV = high risk human
papillomavirus, Pap = Papanicolaou, USPSTF = U.S. Preventive Services Task
Force. | | aAdequate prior screening is defined as three
consecutive negative cytology results (or two consecutive negative co-testing
results) within the past 10 years, with the most recent test occurring within the
past 5 years. |
|
12 . According to established guidelines, cervical cancer screening should begin at
| A) | | menarche. |
| B) | | 18 years of age. |
| C) | | 21 years of age. |
| D) | | the age of sexual initiation. |
The USPSTF and the ACS/ASCCP/ASCP recommend that cervical
screening should begin at 21 years of age [105,106]. This age was
established because studies showed that screening of women in their teens was associated
with few detected cases of cancer and a high number of false-positive test results [107]. Screening is not recommended for women
younger than 21 years of age regardless of the age at which sexual activity began or of
other risk factors [105].
13 . Which of the following cervical cancer screening recommendations is guideline consistent for an asymptomatic woman, 67 years of age, who has had negative results on three consecutive Pap tests within the past 10 years?
| A) | | No screening |
| B) | | Screening with cytology alone every 3 years |
| C) | | Screening with cytology alone every 5 years |
| D) | | Screening with cytology and HPV testing every 5 years |
The USPSTF recommends the discontinuation of screening at
65 years of age for women who have had adequate prior screenings and are not otherwise at
high risk for cervical cancer, as screening offers little to no benefit for women in this
age-group [106]. Adequate prior screening
is defined as three consecutive negative cytology results (or two consecutive negative
co-testing results) within the past 10 years, with the most recent test occurring within
the past 5 years. The recommendation in the ACS/ASCCP/ASCP guideline is similar, with the
added note that screening can be discontinued after 65 years of age for women who have no
history of cervical intraepithelial neoplasia grade 2 or higher within the past 20 years
[105]. In addition, screening should not
begin again in older women for any reason, including a new sexual partner.
14 . A woman has a negative result on cytology testing and a positive result on HPV testing. Which of the following is the most appropriate next step?
| A) | | Referral for colposcopy |
| B) | | Continuation of routine screening |
| C) | | Repeat cytology testing in 6 months |
| D) | | Repeat cytology and HPV testing in 12 months |
A positive HPV result with a negative cytology result
occurs in approximately 11% of women 30 to 34 years of age and in 2.6% of women 60 to 65
years of age [109]. Direct referral for
colposcopy should not be done for women who have a negative cytology result with a
positive HPV result [105]. Instead, the
ACS/ASCCP/ASCP guideline recommends that repeat co-testing be done in 12 months for women
with these results. If either repeat test is positive, colposcopy is recommended; if both
tests are negative, routine screening may be resumed [105]. Alternatively, women who have a negative cytology result and a
positive HPV result may have HPV genotype-specific testing for HPV16 alone or for
HPV16/18. Colposcopy is recommended if either test is positive; if testing results are
negative, co-testing should be repeated in 12 months.
15 . Which of the following cervical cancer screening recommendations is guideline consistent for a woman who is 35 years of age and receives chronic treatment with corticosteroids?
| A) | | Screening every six months in the first year after treatment |
| B) | | Screening every year for the first two years after treatment |
| C) | | Screening every year beginning at the time of treatment |
| D) | | Screening every three years beginning at the time of treatment |
The ACS recommends following guidelines of the U.S. Public
Health Service and the Infectious Disease Society of America for screening of women with a
compromised immune system [42]. These
guidelines indicate that cervical screening be carried out twice within the first year after
diagnosis or treatment and annually thereafter. As with women exposed to DES, there is no
specific age at which to stop screening [42].
16 . All guidelines recommend beginning colorectal cancer screening at what age for people at average risk for the disease?
| A) | | 35 years of age |
| B) | | 40 years of age |
| C) | | 50 years of age |
| D) | | 65 years of age |
Most guidelines recommend beginning colorectal cancer
screening at 50 years of age for people at average risk for the disease [115,116,117,118,122]. The 2009 update of the American College of Gastroenterology (ACG)
guideline recommends that screening begin at 45 years of age for Black individuals because
of the higher incidence of colorectal cancer and related mortality in that population, as
well as an earlier average age at the time of diagnosis [116].
17 . Which of the following recommendations for colorectal cancer screening in average-risk individuals is consistent with guidelines?
| A) | | CT colonography every 10 years |
| B) | | Colonoscopy and stool-based testing every year |
| C) | | Flexible sigmoidoscopy and stool-based testing every year |
| D) | | Flexible sigmoidoscopy every 5 years and stool- based testing every year |
RECOMMENDATIONS FOR COLORECTAL CANCER SCREENING FOR AVERAGE-RISK MEN AND WOMEN
BEGINNING AT 50 YEARS OF AGE
| Screening Recommendation | Notes |
|---|
| Method | Interval |
|---|
| Flexible sigmoidoscopy | 5 years | May be performed alone or in conjunction with annual stool-based test |
| Colonoscopy | 10 years | Repeat in 5 years if polyps found |
| CT colonography | 5 years | — |
| Stool-based test (FOBT or FIT) | 1 year | Must have high sensitivity for detecting cancer |
| Stool DNA test (sDNA) | Uncertain | — |
| Double-contrast barium enema | 5 years | Recommended only in the ACS/USMSTF/ACR guideline |
| CT = computed tomography, FIT = fecal
immunohistochemical test, FOBT = fecal occult blood test. |
18 . An asymptomatic woman who is 36 years of age tells her primary care provider that early adenomas were found on colonoscopy in her father and older brother. Which of the following screening recommendations is guideline consistent for this patient?
| A) | | No screening |
| B) | | Colonoscopy |
| C) | | Stool-based testing alone |
| D) | | Flexible sigmoidoscopy and stool-based testing |
RECOMMENDATIONS FOR COLORECTAL CANCER SCREENING FOR HIGH-RISK MEN AND WOMEN
| Risk Factor | Screening Recommendations |
|---|
| ACS/USMTF/ACR | NCCN | ACG |
|---|
| Family history |
| One first-degree relative with colorectal cancer or advanced adenoma
diagnosed before 60 years of age OR two first-degree relatives with colorectal
cancer or advanced adenoma | Colonoscopy every 5 years beginning at 40 years of age, or 10 years younger
than age at diagnosis of the youngest affected relative | Colonoscopy every 5 years beginning at 40 years of age, or 10 years younger
than age at diagnosis of the youngest affected relative | Colonoscopy every 5 years beginning at 40 years of age, or 10 years younger
than age at diagnosis of the youngest affected relative |
| Second- and third-degree relative with colorectal cancer diagnosed at any
age | — | Colonoscopy every 5 to 10 years beginning at 50 years of age | — |
| Colorectal cancer or adenomatous polyps in first-degree relative diagnosed at
60 years of age or older OR in two second-degree relatives with colorectal
cancer | Screening options as for average-risk individuals, but beginning at 40 years
of age | — | — |
| Personal history |
| Adenomatous polyp |
| 1 or 2 small tubular adenomas with low-grade dysplasia: Colonoscopy at 5
to 10 years | | 3 to 10 adenomas or 1 adenoma 1 cm or any adenoma with villous features
or high-grade dysplasia: Colonoscopy at 3 years |
|
Low-risk adenomatous polyps: Repeat colonoscopy within 5 years; if no
polyps, repeat every 10 years
Advanced or multiple adenomatous polyps: Repeat colonoscopy within 3 years;
if no polyps, repeat within 5 years
| — |
| Inflammatory bowel disease, chronic ulcerative colitis, or Crohn
disease | Colonoscopy every 1 to 2 years with biopsies for dysplasia, beginning 8 years
after the onset of pancolitis | Colonoscopy every 1 to 2 years beginning 8 to 10 years after onset of
symptoms of pancolitis | — |
| Hereditary syndromes |
| Lynch syndrome (MLH1 and MSH2 mutations) | Colonoscopy every 1 to 2 years beginning at 20 to 25 years of age or 10 years
younger than age at diagnosis of the youngest affected relative | Colonoscopy every 1 to 2 years beginning at 20 to 25 years of age or 2 to 5
years younger than age at diagnosis of the youngest affected relative if diagnosed
before 25 years of age | Colonoscopy every 2 years beginning at 20 to 25 years of age and then
annually after 40 years of age |
| Juvenile polyposis syndrome | — | Colonoscopy every year if polyps found or every 2 to 3 years if no polyps
found beginning at 12 to 15 years of age | — |
| Peutz-Jeghers syndrome | — | Colonoscopy every 2 to 3 years beginning in the late teenage years | — |
| ACG = American College of Gastroenterology,
ACS/USMSTF/ACR = American Cancer Society/U.S. Multisociety Task Force on
Colorectal Cancer/American College of Radiology, NCCN = National Comprehensive
Cancer Network. |
19 . An asymptomatic woman who is 48 years of age tells her primary care provider that colorectal cancer was diagnosed in her sister at 58 years of age. No cancers have been diagnosed in any other family members. Which of the following colorectal cancer screening recommendations is guideline consistent?
| A) | | Colonoscopy every 5 years |
| B) | | Colonoscopy every 10 years |
| C) | | Flexible sigmoidoscopy and stool-based testing every year |
| D) | | Flexible sigmoidoscopy and stool-based testing every 2 years |
RECOMMENDATIONS FOR COLORECTAL CANCER SCREENING FOR HIGH-RISK MEN AND WOMEN
| Risk Factor | Screening Recommendations |
|---|
| ACS/USMTF/ACR | NCCN | ACG |
|---|
| Family history |
| One first-degree relative with colorectal cancer or advanced adenoma
diagnosed before 60 years of age OR two first-degree relatives with colorectal
cancer or advanced adenoma | Colonoscopy every 5 years beginning at 40 years of age, or 10 years younger
than age at diagnosis of the youngest affected relative | Colonoscopy every 5 years beginning at 40 years of age, or 10 years younger
than age at diagnosis of the youngest affected relative | Colonoscopy every 5 years beginning at 40 years of age, or 10 years younger
than age at diagnosis of the youngest affected relative |
| Second- and third-degree relative with colorectal cancer diagnosed at any
age | — | Colonoscopy every 5 to 10 years beginning at 50 years of age | — |
| Colorectal cancer or adenomatous polyps in first-degree relative diagnosed at
60 years of age or older OR in two second-degree relatives with colorectal
cancer | Screening options as for average-risk individuals, but beginning at 40 years
of age | — | — |
| Personal history |
| Adenomatous polyp |
| 1 or 2 small tubular adenomas with low-grade dysplasia: Colonoscopy at 5
to 10 years | | 3 to 10 adenomas or 1 adenoma 1 cm or any adenoma with villous features
or high-grade dysplasia: Colonoscopy at 3 years |
|
Low-risk adenomatous polyps: Repeat colonoscopy within 5 years; if no
polyps, repeat every 10 years
Advanced or multiple adenomatous polyps: Repeat colonoscopy within 3 years;
if no polyps, repeat within 5 years
| — |
| Inflammatory bowel disease, chronic ulcerative colitis, or Crohn
disease | Colonoscopy every 1 to 2 years with biopsies for dysplasia, beginning 8 years
after the onset of pancolitis | Colonoscopy every 1 to 2 years beginning 8 to 10 years after onset of
symptoms of pancolitis | — |
| Hereditary syndromes |
| Lynch syndrome (MLH1 and MSH2 mutations) | Colonoscopy every 1 to 2 years beginning at 20 to 25 years of age or 10 years
younger than age at diagnosis of the youngest affected relative | Colonoscopy every 1 to 2 years beginning at 20 to 25 years of age or 2 to 5
years younger than age at diagnosis of the youngest affected relative if diagnosed
before 25 years of age | Colonoscopy every 2 years beginning at 20 to 25 years of age and then
annually after 40 years of age |
| Juvenile polyposis syndrome | — | Colonoscopy every year if polyps found or every 2 to 3 years if no polyps
found beginning at 12 to 15 years of age | — |
| Peutz-Jeghers syndrome | — | Colonoscopy every 2 to 3 years beginning in the late teenage years | — |
| ACG = American College of Gastroenterology,
ACS/USMSTF/ACR = American Cancer Society/U.S. Multisociety Task Force on
Colorectal Cancer/American College of Radiology, NCCN = National Comprehensive
Cancer Network. |
20 . An asymptomatic man at average risk for colorectal cancer is found to have low-risk adenomatous polyps on sigmoidoscopy. Which of the following is the most appropriate next step?
| A) | | Colonoscopy within 5 years |
| B) | | Flexible sigmoidoscopy within 1 year |
| C) | | Fecal occult blood test within 6 months |
| D) | | Double-contrast barium enema within 1 year |
RECOMMENDATIONS FOR COLORECTAL CANCER SCREENING FOR HIGH-RISK MEN AND WOMEN
| Risk Factor | Screening Recommendations |
|---|
| ACS/USMTF/ACR | NCCN | ACG |
|---|
| Family history |
| One first-degree relative with colorectal cancer or advanced adenoma
diagnosed before 60 years of age OR two first-degree relatives with colorectal
cancer or advanced adenoma | Colonoscopy every 5 years beginning at 40 years of age, or 10 years younger
than age at diagnosis of the youngest affected relative | Colonoscopy every 5 years beginning at 40 years of age, or 10 years younger
than age at diagnosis of the youngest affected relative | Colonoscopy every 5 years beginning at 40 years of age, or 10 years younger
than age at diagnosis of the youngest affected relative |
| Second- and third-degree relative with colorectal cancer diagnosed at any
age | — | Colonoscopy every 5 to 10 years beginning at 50 years of age | — |
| Colorectal cancer or adenomatous polyps in first-degree relative diagnosed at
60 years of age or older OR in two second-degree relatives with colorectal
cancer | Screening options as for average-risk individuals, but beginning at 40 years
of age | — | — |
| Personal history |
| Adenomatous polyp |
| 1 or 2 small tubular adenomas with low-grade dysplasia: Colonoscopy at 5
to 10 years | | 3 to 10 adenomas or 1 adenoma 1 cm or any adenoma with villous features
or high-grade dysplasia: Colonoscopy at 3 years |
|
Low-risk adenomatous polyps: Repeat colonoscopy within 5 years; if no
polyps, repeat every 10 years
Advanced or multiple adenomatous polyps: Repeat colonoscopy within 3 years;
if no polyps, repeat within 5 years
| — |
| Inflammatory bowel disease, chronic ulcerative colitis, or Crohn
disease | Colonoscopy every 1 to 2 years with biopsies for dysplasia, beginning 8 years
after the onset of pancolitis | Colonoscopy every 1 to 2 years beginning 8 to 10 years after onset of
symptoms of pancolitis | — |
| Hereditary syndromes |
| Lynch syndrome (MLH1 and MSH2 mutations) | Colonoscopy every 1 to 2 years beginning at 20 to 25 years of age or 10 years
younger than age at diagnosis of the youngest affected relative | Colonoscopy every 1 to 2 years beginning at 20 to 25 years of age or 2 to 5
years younger than age at diagnosis of the youngest affected relative if diagnosed
before 25 years of age | Colonoscopy every 2 years beginning at 20 to 25 years of age and then
annually after 40 years of age |
| Juvenile polyposis syndrome | — | Colonoscopy every year if polyps found or every 2 to 3 years if no polyps
found beginning at 12 to 15 years of age | — |
| Peutz-Jeghers syndrome | — | Colonoscopy every 2 to 3 years beginning in the late teenage years | — |
| ACG = American College of Gastroenterology,
ACS/USMSTF/ACR = American Cancer Society/U.S. Multisociety Task Force on
Colorectal Cancer/American College of Radiology, NCCN = National Comprehensive
Cancer Network. |
21 . Which of the following colorectal screening tests has been associated with a reduction in colorectal cancer-specific mortality of more than 60%?
| A) | | Colonoscopy |
| B) | | Flexible sigmoidoscopy |
| C) | | Fecal occult blood testing |
| D) | | Fecal immunohistochemical testing |
In a meta-analysis (nine studies), flexible sigmoidoscopy
was associated with a 28% reduction in mortality compared with no screening [131]. Similar reviews have shown that FOBT
(either annually or biennially) led to a 14% to 15% reduction in colorectal cancer-related
mortality [131,134]. The positive impact of FOBT was
supported by the results of long-term follow-up of more than 46,000 people (50 to 80 years
of age) in the Minnesota Colon Cancer Control Study [46]. The participants in this study were randomly assigned to usual care
(control) or to annual or biennial FOBT. Through 30 years of follow-up, screening reduced
colorectal cancer-related mortality by 32% (annual screening) and 22% (biennial screening)
compared with no screening. There was no reduction in all-cause mortality. The findings in
this population suggest that the effect of screening persists after screening has stopped
[135].
Another large, long-term study provides evidence of the
effect of endoscopic screening on mortality. In this study, nearly 89,000 participants in
the Nurses' Health Study and the Health Professionals Follow-up Study were followed up for
more than 22 years. Compared with no endoscopic screening, sigmoidoscopy and colonoscopy
were associated with a lower incidence of distal colorectal cancer, and colonoscopy was
associated with a modestly lower incidence of proximal colon cancer as well [47]. The total number of colorectal cancers
diagnosed was 1,164 in the group that had no screening, 82 in the group that had
endoscopic polypectomy, 348 in the group that had sigmoidoscopy, and 221 in the group that
had colonoscopy. Multivariate analysis demonstrated that these data represent incidence
reductions of 43%, 40%, and 56%, respectively. Both types of endoscopic screening were
also associated with lower mortality. The number of deaths in the no-screening group was
349, compared with 73 and 52 in the sigmoidoscopy and colonoscopy groups, respectively.
According to multivariate analysis, these data represent mortality reductions of 41% and
68%. An analysis of trends in the incidence of colorectal cancer and related mortality
from 2015 to 2019 demonstrated an overall decrease in the incidence of colorectal cancer;
however, rising rates of obesity, diabetes, and physical inactivity are believed to be
contributing to upward trends of new colorectal cancer cases [136].
22 . Guidelines for lung cancer screening recommend against screening for people
| A) | | between 55 and 74 years of age. |
| B) | | with smoking cessation of 10 years. |
| C) | | with a 35 pack-year history of smoking. |
| D) | | with severe comorbidities that preclude potentially curative treatment. |
Lung cancer screening is not recommended for asymptomatic
persons with low or moderate risk for lung cancer. The definition of low or moderate risk
differs slightly among guidelines. The NCCN guideline defines low risk as an age younger
than 50 years and/or a history of smoking of less than 20 pack-years [146]. The American College of Chest Physicians
(ACCP) defines low or moderate risk as an age younger than 55 years, a history of smoking of
fewer than 30 pack-years, or smoking cessation more than 15 years previously [147]. Guidelines also recommend against
screening for people with severe comorbidities that would preclude potentially curative
treatment and/or limit life expectancy [50,51,144,147].
23 . Which of the following statements about lung cancer screening is TRUE?
| A) | | Only former smokers should be offered lung cancer screening. |
| B) | | Approximately 50% of the U.S. population meet the criteria for lung cancer screening. |
| C) | | Asymptomatic individuals who are at high risk and older than 75 years of age should not be offered lung cancer screening. |
| D) | | The best balance of benefits and harms of lung cancer screening is found among individuals at moderate risk for lung cancer. |
Lung cancer screening is not recommended for asymptomatic
persons with low or moderate risk for lung cancer. The definition of low or moderate risk
differs slightly among guidelines. The NCCN guideline defines low risk as an age younger
than 50 years and/or a history of smoking of less than 20 pack-years [146]. The American College of Chest Physicians
(ACCP) defines low or moderate risk as an age younger than 55 years, a history of smoking of
fewer than 30 pack-years, or smoking cessation more than 15 years previously [147]. Guidelines also recommend against
screening for people with severe comorbidities that would preclude potentially curative
treatment and/or limit life expectancy [50,51,144,147].
High risk for lung cancer was defined in the largest
randomized controlled trial of lung cancer screening trial in the United States to date
(50,000 individuals), the NLST [50]. In that
trial, high risk was based on patient age and smoking history (i.e., number of pack-years,
smoking status, and time since smoking cessation), with the following criteria:
Age of 55 to 74 years
History of current or former smoking
Smoking history of at least 30 pack-years
Smoking cessation of fewer than 15 years for former smokers
This definition of high risk is based on research showing
that the incidence of lung cancer is relatively low before 50 years of age but increases
with age, especially after the age of 60 years, and that age-specific incidence rates
increase with cumulative exposure to tobacco smoke [51,146,148]. Guidelines have modeled the definition of
high risk on these criteria. Analysis of data from 2010 has indicated that approximately 8.6
million people in the United States (5.2 million men and 3.4 million women) were eligible
for lung cancer screening based on the NLST eligibility criteria [149]. However, this number represents only
approximately 27% of all individuals in whom lung cancer is diagnosed in the United States
[150]. Other risk models are being
explored to determine if the inclusion of additional risk factors will help better select
candidates for screening.
The American Society of Clinical Oncology (ASCO), the
NCCN, the ACS, and the ACCP, with input from the American Thoracic Society (ATS),
collaborated on a literature review on lung cancer screening from which evidence-based
guidelines were developed [144]. According
to these guidelines, screening is recommended for individuals 55 to 74 years of age who
are current or former smokers who have (or had) smoked for at least 30 pack-years and, if
a former smoker, who has quit within the past 15 years [144]. Guidelines established individually by these organizations, as well
as by the American Lung Association, define high risk similarly [146,147,151,152,153]. In 2020, the NCCN revised its screening recommendations to include
individuals 50 years or older with a 20 or more pack-year smoking history [146]. The pack-year threshold was lowered
from 30 based on trial data suggesting that lung cancer risk for individuals with a 20–29
pack-year smoking history is similar to that of individuals with a 30 or more pack-year
history. The age range was lowered (from 55 to 50) for several reasons, including the
observation that approximately 5.6% of lung cancer is diagnosed in patients 45 to 54 years
of age. The NCCN felt that these changes would help reduce disparities in LDCT screening
for Black patients and to a lesser degree in women [146]. Citing uncertainty about the appropriate duration of screening and
the age at which screening is no longer appropriate, as well as reports that approximately
27% of lung cancer is diagnosed in patients 75 to 84 years of age, the NCCN removed an
upper age cutoff for lung cancer screening [146]. The NCCN also has not placed a time limit for screening eligibility
after smoking cessation, citing that the 15-year restriction is not based on or justified
by evidence [146]. In its own guideline,
the ATS notes that screening may begin at 50 years of age for individuals who have a 20
pack-year history of smoking and one additional comorbidity that results in a 5%
cumulative risk of lung cancer developing over the next five years [154].
24 . Which of the following was the most common harm associated with lung cancer screening in the National Lung Screening Trial?
| A) | | Overdiagnosis |
| B) | | False-positive results |
| C) | | Unnecessary clinical procedure |
| D) | | Unnecessary diagnostic procedure |
Rates of false-positive results with LDCT screening are
high. Overall, studies have shown that screening with LDCT has identified small nodules in
10% to 50% of individuals screened, and the vast majority of these nodules will be found to
be benign [147]. In the NLST, 96.4% of the
positive screening results in the LDCT group were false-positive (compared with 94.5% in the
radiography group) [50]. The rate of biopsy
for nodules later found to be benign has varied, with an average of approximately 30% [147]. False-positive results are associated
with psychologic distress for patients and the potential for unnecessary follow-up
procedures or treatment. Over the three rounds of screening in the NLST, approximately 72%
of individuals with a positive result had diagnostic follow-up of some type, 59% had a
clinical procedure, and 4% had a surgical procedure [50]. Major complications in individuals with nodules that proved to be
benign were rare (0.1%) [50].
25 . Before lung cancer screening guidelines were published, which of the following screening tests did physicians order most often?
| A) | | Sputum cytology alone |
| B) | | Chest radiography alone |
| C) | | Low-dose computed tomography |
| D) | | Sputum cytology and chest radiography |
Many healthcare professionals screened for lung cancer
before it was recommended, with most using screening tools that have not been associated
with decreased mortality. For example, in a survey of 962 physicians (family physicians,
general practitioners, and general internists), 55% said they had ordered chest radiography
and fewer than 5% had ordered sputum cytology; 22% had ordered LDCT [14]. Several physician-related factors
associated with lung cancer screening (before it was recommended) were identified [14,38]:
Perception of a screening test's effectiveness
Attitude toward recommended screening guidelines
Practice experience
Perception of a patient's risk for lung cancer
Reimbursement and payment for screening
Concern about litigation
Patient request for screening
Since the publication of guidelines for lung cancer
screening, a small study of 15 leading academic medical centers that offer screening showed
that 11 (73%) of the centers limit screening to individuals at high risk as defined in the
NLST; one center followed expanded selection criteria, and three centers offered lung cancer
screening to any individuals who had participated in shared decision making with a physician
[161].
26 . Routine prostate cancer screening is recommended by the
| A) | | American College of Physicians. |
| B) | | American Urological Association. |
| C) | | U.S. Preventive Services Task Force. |
| D) | | None of the above |
RECOMMENDATIONS FOR PROSTATE CANCER SCREENING
| Organization (Year) | Screening Recommendation | Notes |
|---|
| National Comprehensive Cancer Network (2022) | No routine screening | Begin risk-benefit discussion about baseline DRE and PSA screening at 45 years of
age. It is reasonable to consider beginning shared decision-making about PSA screening
at 40 years of age for African-American men. |
| American Cancer Society (2013, reconfirmed 2019) | No routine screening | Discuss the potential benefits, risks, and uncertainties associated with prostate
cancer screening with men who have a life expectancy of at least 10 years; prostate
cancer screening should not occur without an informed decision-making process. |
| U.S. Preventive Services Task Force (2018) | No routine screening | Discuss the potential benefits and harms of screening with men 55 to 69 years of
age. Do not screen men who do not express a preference for screening. Do not routinely
screen men 70 years of age and older. |
| American Urological Association (2013 reconfirmed 2018) | No routine screening |
| Decisions should be individualized for men younger than 55 years of age who
are at high risk. | | Shared decision making should take place for men 55 to 69 years of age, for
whom screening is of greatest benefit. |
|
| American College of Physicians (2013) | No routine screening with PSA for average-risk men younger than 50 years of age,
men older than 69 years of age, or men with a life expectancy of less than 10 to 15
years | Clinicians should inform their patients 50 to 69 years of age about the limited
potential benefits and substantial harms of screening. |
| American Society of Clinical Oncology (2012) | Discourage general screening for men with a life expectancy of ≤10 years, as the
harms outweigh the benefits. | Discuss the individual appropriateness of screening with men who have a life
expectancy >10 years. |
| DRE = digital rectal examination, PSA =
prostate-specific antigen. |
27 . A man who is 45 years of age and at high risk for prostate cancer opts to have screening, and the initial prostate-specific antigen (PSA) level is 0.7 ng/mL. Which of the following recommendations is guideline consistent?
| A) | | Repeat PSA in 1 year |
| B) | | Repeat PSA in 2 to 4 years |
| C) | | Repeat PSA at 50 years of age |
| D) | | Discussion of the harms and benefits of screening |
The NCCN recommends baseline PSA testing and consideration
of DRE for men who are identified as being at high risk, defined as Black race or family
history of prostate cancer [165]. If the
initial discussion of screening (at 45 years of age) results in measurement of PSA and the
level is less than 1.0 ng/mL, a repeat PSA should be done every two to four years [165]. If the PSA level is 1–3 ng/mL and DRE is
normal (if performed), repeat testing is recommended at one- to two-year intervals. A PSA
level higher than 3.0 ng/mL with a very suspicious DRE finding should prompt a discussion of
further testing, including percent-free PSA testing, 4Kscore, or prostate health index blood
testing; a repeat PSA/DRE in 6 to 12 months; or a biopsy [165].
28 . The primary benefit of prostate cancer screening is
| A) | | reduced mortality. |
| B) | | increased five-year survival. |
| C) | | lower stage and grade of cancer at diagnosis. |
| D) | | lower incidence of prostate cancer. |
The primary benefit of prostate cancer screening is a
lower stage and grade of cancer at the time of diagnosis [42,49,167]. However, despite
this benefit, an effect of screening on mortality has not been clearly demonstrated. After
13 years of follow-up in the PLCO trial, there was no benefit of annual screening on
mortality [168]. A subsequent
meta-analysis (five randomized controlled trials) similarly demonstrated no effect of
screening on prostate cancer-specific or overall mortality [169]. However, data from the European
Randomized Study of Screening for Prostate Cancer demonstrated that screening reduced the
risk for prostate cancer death by 7% to 9% per year [170].
29 . Which of the following statements about oral cancer screening is TRUE?
| A) | | Toluidine blue enhances the efficacy of oral cancer screening. |
| B) | | Oral cancer screening has reduced mortality among individuals at average risk and high risk. |
| C) | | No organization recommends examination of the oral cavity to detect oral cancer or premalignant lesions. |
| D) | | Routine screening for oral cancer or premalignant lesions should be carried out by dental care providers. |
In 2010, an expert panel from the American Dental
Association Council on Scientific Affairs developed recommendations for oral cancer
screening on the basis of five systematic reviews and four clinical studies [179]. The panel concluded that community-based
screening by visual and tactile examination may not alter disease-specific mortality among
the general population but may decrease disease-specific mortality among people who use
tobacco, alcohol, or both [179]. In
addition, screening may result in detection of oral cancers at early stages of development
(stages I and II). The panel found insufficient evidence to determine whether screening
alters disease-specific mortality among asymptomatic people seeking dental care. There was
also insufficient evidence that devices based on autofluorescence or tissue reflectance
enhanced the detection of potentially malignant lesions beyond that detected by a
conventional visual and tactile examination. The panel suggested that "clinicians remain
alert for signs of potentially malignant lesions or early-stage cancers in all patients
while performing routine visual and tactile examinations," especially for patients who use
tobacco or who are considered to be heavy users of alcohol (defined as an average of more
than two drinks per day for men and more than one drink per day for women) [179].
Similarly, the authors of a 2013 meta-analysis on the
effectiveness of screening programs for oral cancer found that population-based screening
reduced the mortality rate of oral cancer only among high-risk individuals but not among
individuals at average risk [180]. Visual
examination as part of a screening program significantly reduced mortality by 24% among
individuals with a history of alcohol or tobacco use, or both, compared with unscreened
individuals [180]. However, the authors of
the meta-analysis noted that the evidence was limited to one study with a high risk of bias.
As with the American Dental Association review, no evidence supported a reduction in
mortality with the use of other screening tools, such as toluidine blue, brush biopsy, or
fluorescence imaging.
30 . Which of the following ovarian cancer screening recommendations is guideline consistent for an asymptomatic woman 45 years of age at average risk for ovarian cancer?
| A) | | No screening |
| B) | | Pelvic examination alone every year |
| C) | | Transvaginal ultrasound and CA-125 level every 2 years |
| D) | | Pelvic examination and transvaginal ultrasound every 2 years |
The combination of CA-125 and transvaginal ultrasound for
ovarian cancer screening among women at average risk was evaluated in the PLCO cancer
screening trial. The study enrolled more than 78,000 women, 55 to 74 years of age, who were
randomly assigned to annual screening for 6 years or usual care and were followed for a
maximum of 13 years. The mortality rate was similar for both groups (3.1 ovarian
cancer-related deaths per 10,000 patient-years in the group who had screening vs. 2.6 deaths
per 10,000 patient-years in the group who had usual care) [188]. As a result of these and similar
findings, major medical organizations agree that ovarian cancer screening is not recommended
for asymptomatic women at average risk for the disease [187,189,190]. CA-125 is a promising biomarker for
screening for ovarian cancer, but it does not yet have an acceptable accuracy in
population-based screening [191].
Additionally, ACOG and the USPSTF note that substantial harms may be involved with ovarian
cancer screening, primarily due to surgical interventions for masses that are not cancerous
[189,190].
