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Practices of Cancer Screening In developed and developing countries
- 1. Practices of Cancer Screening in Abroad and Bangladesh Julfikar Saif Resident Department of Oncology BSMMU
- 2. What is Screening? • Screening is defined as the presumptive identification of unrecognized disease in an apparently healthy, asymptomatic population by means of tests, examinations or other procedures that can be applied rapidly and easily to the target population.
- 3. Screening?
- 4. Ideal Criteria of introducing population screening • The condition should be an important health problem • Natural history of the condition should be adequately understood • There should be a recognizable latent or asymptomatic stage • There should be a suitable test or examination that has a high level of accuracy • The test should be acceptable to the population
- 5. Continued… • Acceptable treatment available for disease • There should be an agreed policy on whom to treat as patients • Facilities for diagnosis & treatment should be available • The cost of screening+diagnosis+treatment should be realistically feasible • Screening should be a continuing process and not a ‘once and for all’ project.
- 6. Background • In 1907, Dr. Charles Childe published a book entitled The Control of a Scourge, Or How Cancer Is Curable. In it, he described the high mortality rates due to cancer as tragically unnecessary, and put “the finger on the flaw” • In the 1920s, The American Medical Association (AMA) endorsed use of the periodic health exam for early detection of a number of diseases including cancer • The test was invented by and named after the Greek-American doctor Georgios Papanikolaou, who started his research in 1923 • American Society for the Contol of Cancer (ASCC) in 1913. The ASCC would change its name to the American Cancer Society in 1945. The Women’s Field Army of the ASCC was formed in the 1930s.5 This army of 150,000 women went neighborhood by neighborhood teaching the virtues of early detection of cancer (Figure 1). The Field Army focused on educating the public on the early warning signs of cancer and breast self-examination. • By mid1940s pap smear program showed its benefits of early detection with nationwide adoption by 1960s
- 7. Cancer screening in developed countries
- 8. Cancer Screening in USA • Breast Cancer • Cervical Cancer • Endometrial Cancer • Lung Cancer • Colorectal Cancer • Prostate Cancer
- 9. Breast Cancer Age Group Investigation Recommendation 40-44 year women Mammography Women should be given choice/opportunity to start annual screening 45-54 years women Mammography Annual screening At or above 55 years women Mammography Biennial screening May choose annual screening Continue until one has 10 year life expectancy
- 10. Cervical Cancer Age Group Investigation Recommendation 21-29 years women Pap test Should start from 21 years, 3 yearly 30-65 years women Pap test and HPV DNA test Both test 5yearly is preferred, 3yearly pap only is acceptable >65 years women Pap test and HPV DNA test May stop if 3 or more negative pap only or 2 or more pap+DNA test negative if last negative test within 5years Women who underwent total hysterectomy Stop screening
- 11. Endometrial Cancer Age group Intervention Recommendation Women at menopause At the time of menopause, women are informed about risks and symptoms of endometrial cancer and strongly encouraged to report any unexpected bleeding or spotting to their physicians
- 12. Colorectal Cancer Age group Intervention Recommendation 45-75 years FIT/FOBT annually or Multitarget stool DNA 3yearly or CT colonography/flexible sigmoidoscopy 5 yearly or colonoscopy 10yearly Test is selected as per patient’s choice, if any non colonoscopy test 76-85years Individualize decisission according to patient’s choice, life expectancy etc >85 years Should be discouraged from screening
- 13. Lung Cancer Age Group Investigation Recommendation Current or former smokers aged 55‐74 y in good health with at least a 30–pack‐y history of smoking Low‐dose helical CT Annual screening if, #current smoker or quitted within past 15 years and #30 pack year smoking and #Receive evidence based smoking cessation advice if current smoker and #Knows risk-benefit of screening test and gave informed consent and #has access to high quality high volume screening and treatment center
- 14. Prostate cancer Age Group Investigation Recommendation Men at or above 50 years PSA with or without DRE Men with at least 10 year life expectancy after knowing all the risk-benefit and uncertainties associated with such screening are presented with opportunity to choose to go for screening or not
- 15. Cancer screening under NHS • Cervical Cancer • Breast Cancer • Colorectal Cancer
- 16. Cervical Cancer Group Investigation Recommendatio n 25-49 years women and trans men HPV and Liquid Based Cytology 3 yearly 50-64 years women and trans men HPV and Liquid Based Cytology 5 yearly
- 17. Breast Cancer Group Investigation Recommendation 50-70 years women Mammography 3 yearly for 7 total visits usually >70 years women Mammography May choose to continue 3yearly breast screening but has to make own appointment
- 18. Colorectal Cancer Group Investigation Recommendation 50/60-74 years *FIT/FOB 2 yearly 55 year Colonoscopy One off test, only practiced in England Above 74 years May ask for FIT kit 2 yearly
- 19. Cancer screening under NHS • Lung cancer – NHS is starting lung cancer screening under the umbrella of lung health check up in some parts of UK from autumn 2019 • Prostate cancer – No national program as NHS regards current tests unreliable and doesn’t reduce mortality
- 20. Cancer screening in Japan • Gastric Cancer • Lung Cancer • Colorectal Cancer • Breast Cancer • Cervical Cancer
- 21. Gastric Cancer Group Investigation Recommendation >50 years Endoscopy of upper GI Gastric X ray examination 2-3 yearly Pepsinogen method Helicobacter Pylori detection At the discretion of subject
- 22. Lung Cancer Group Investigation Recommendation >40 years Chest Xray ± Sputum cytology CXR only for Non high risk group Both for high risk group LDCT Not recommended but maybe performed based on subject’s choice
- 23. Cancer screening in developing countries
- 24. Cancer screening in India • Place? – Community health center / Sub-center / Primary health center • Personnel? – Auxiliary Nurse Midwife/Mid level providers/Nurse
- 25. Continued… Type of cancer Age Method of Screening Frequency of Screening If Positive Oral 30-65 years Oral Visual Examination (OVE) 5yearly Referred to ENT specialist/surgeon/dentist/MO for confirmation if needed biopsy Cervical 30-65 years Visual Inspection With acetic acid (VIA) Referred to facilities where gynaecologist or trained lady medical officer available Breast 30-65 years Clinical breast Examination Referred surgeon for confirmation using breast USG followed by biopsy as appropriate
- 26. Continued… • Cost? – For VIA- examination lamp, Cusco’s speculum, autoclave, torch = 20000 Rs. – For OVE- Mouth mirror, LED torch = 3000 Rs – Consumables for VIA- gloves, cotton swab, distilled water, acetic acid= 10 Rs/capita – For OVE- wooden stick, glove, cotton, gauze= 10Rs per capita
- 27. Cancer screening scenario in Bangladesh
- 28. Continued… • Common Cancers in male
- 29. Continued… • Common Cancers in female
- 30. Continued… • Timeline – In 2005 government adopted opportunistic cervical cancer screening at district level – In 2006 National Cervical and Breast Cancer Screening Program launched with strong support from BSMMU and UNFPA – From 2012 the program is being extended to Upazila
- 31. Continued… • Target Population – 30-60 years women • Frequency – 5yearly
- 32. Continued…
- 33. Continued… • Place? – BSMMU – All medical college hospitals – District Hospital – Maternal Child Welfare Centers – Selected Upazila Health Complexes – Some NGO clinics by trained Family Welfare Visitors/Paramedics/Doctors
- 34. Continued… • Available facilities and technologies – Breast Cancer- Mammography, USG – Lung Cancer- Chest radiograph – Colorectal Cancer- FIT, FOBT, Structural Visual Examination – Prostate Cancer- PSA – Gastric Cancer- UGI endoscopy, Radiograph
- 35. Challenges foreseen by healthcare workers in implementation of population cancer screening program at Silchar Assam