screening in breast and colorectal carcinoma

1. Presented by-Dr Yajnadatta Sarangi
Moderator- Dr Sunil Kumar
Asst. Prof
Dept. of General Surgery

2.  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.  Basic purpose of screening is to sort out,
large group of apparently healthy persons
those likely to have the disease or at
increased risk of disease under study

4.  There should be scientific evidence of
screening programme effectiveness.
 The programme should promote equity and
access to screening for the entire target
population.
 The overall benefits of screening should
outweigh the harm.[9]

5.  Should be common and serious
 Able to achieve accurate detection in early-
stage of disease
 Scientific evidence that screening reduces
mortality from the disease.

6.  In USA and UK screening routinely done
 Guidelines followed in west-NCCN guidelines
which updated every year.
 Most comprehensive guidelines Provided by
NCCN

7. NATIONAL PROGRAMME
FOR
PREVENTION AND CONTROL
OF
CANCER, DIABETES, CARDIOVASCULAR DISEASES AND STROKE
(NPCDCS) 2017
 In India guidelines exist only for
◦ malignancy breast, cervix and oral cancer
 No guidelines - for screening of colorectal
carcinoma in INDIA

8.  Breast screening is performed in women
without any signs or symptoms of breast
cancer so that disease can be detected as
early as possible
 This allows early treatment to reduce
mortality and morbidity.
 Diagnostic breast evaluation differs from
breast screening in that it is used to evaluate
an existing problem e.g. breast lump.

11.  Clinical breast examination
 Breast awareness
 Mammogram
 MRI
 Recently NCCN Recommends digital
tomosynthesis for screening of breast
malignancy

12.  Mammography decrease the risk of death due to breast cancer
by 15%
 Sensitivity-91%
 Specificity lower -81%
 In dense breast sensitivity of mammo-50%

15.  BIRADS 0-review and compare
 BIRADS 1 and 2- cont. screening
 BIRADS 3-diagnostic mammogram every 6 month for 1-2year then
annually
 BIRADS 4,5-image guided core needle biopsy
 BIRADS 6-folllow ca breast management principle

16.  Sensitivity 90% for detecting invasive ca
breast
 Sensitivity of 60% for detecting DCIS
 But with moderate specificity
 MRI cant detect microcalcification
 So role of MRI Controversial and it is
indicated in selected cases only
 COMICE TRIAL-No significant diff between
patients who undergo MRI and who not
 Indication of MRI-CONTD…

18. RECENT NCCN CHANGES
1.FDR of breast cancer genetic mutation carrier but
untested, encourage genetic testing before MRI.
2.life time risk 20% or greater as defined by
models that are largely dependent on family
history…if patients decline genetic testing
recommend MRI
3.In patient with history of thoracic RT
4.Consider MRI screening for LCIS and ALH/ADH if
life time risk more than 20%
WOMEN WITH LIFE TIME RISK OF LESS THAN 15%
MRI NOT RECOMMNDED

19.  3D picturing of breast
 FDA 2011 approved
 NCCN approved in 2019
 Digital mammography depicts 2D view which
allows summation artefacts that increases
recall rate ,
 In patient with dense breast tissue overlaps
occurs which increases false negative rate
 Tomosynthesis do not have these limitation
due to its 3d visualization

21.  Double radiation doses
 Sensitivity ≥ 90%
 Specificity ≥70%

22.  USG used as an adjunct in patient with dense
breast in addition to mammo
 Controversial---USG increases negative
biopsy rate
 Mammo sensitivity in dense breast 50%
 USG+MAMMO in dense breast 77%
 Different RCT failed to prove the efficacy of
USG in screening
 Routine use of USG in screening not
recommended by NCCN

23.  All female
 Its not about age but its all about risk factors

24. FEMALES COMING TO OPD
AVERAGE RISK HIGH RISK
 Consider every female is a potential case of carcinoma
breast case
 NCCN not uses low risk terminology

25.  Prior history of breast cancer
 Women who have a life time risk of ≥20% as
defined by models that are largely dependent on
family history(CLAUS, BRACAPRO , BOADICEA .
TYRER-CUZICK models).
 Patients who receive thoracic RT <30year (mantle
irradiation)
 5-year risk of invasive breast cancer ≥1.7% in
women ≥35 year ( AS per gail model)
 Women with history of LCIS, ADH/ALH (POINT TO
REMEMBER)
 Genetic predisposition present

26.  Current age
 Age at menarche
 Age at first birth or nulliparity
 Number of female first degree relatives with
breast cancer
 Number of previous benign breast biopsies
 Atypical hyperplasia
 Races

28. 1.Age ≥25 year but <40……
clinical encounters every 1-3 year
breast awareness
2. Age ≥40…………
annual clinical encounters
annual screening mammogram
consider tomosynthesis
breast awareness

29. HIGH RISK GROUPS

30.  History and physical examination 1-4 times
per year for 5 yr then annually
 Genetics testing
 Educate about lymph edema management
 Mammography every 12 month
 Screen for metastasis( as clinically indicated)
 Pt adherence to endocrine therapy

31. 1.Clinical encounter Every 6-12 month
-to begin when identified as being at increased risk
but not prior to age 21y
-Referral to genetic counseling or similarly trained
provider,
2.Annual screening mammogram
-to begin 10 years prior to the youngest family
member with breast cancer but not prior to age 30 year
-Consider tomosynthesis
3.Annual breast MRI
-To begin 10 year prior to youngest family
member with breast cancer but not prior to age 25 year
4.risk reduction strategy
5.breast awareness

32.  Current age <25 year
1.annual clinical encounter beginning 10
year after RT
2.Breast awareness
 Current age >25 year
1.clinical encounter begins 10 year after
RT
2.Breast awareness
3.annual screening mammogram
beginning 10 year after RT but not prior to age
30 year
4.annual breast MRI beginning 10 Year
after RT but not prior to age 25 years

33. 1.Clinical encounter Every 6-12 month
-to begin when identified as being at
increased risk by GAIL model
2.Annual screening mammogram
-to begin when identified as being at
increased risk by GAIL model
-Consider tomosynthesis
3.Risk reduction strategy
4.Breast awareness

34. 1.Clinical encounter Every 6-12 month
-to begin at diagnosis of LCIS/ALH
2.Annual screening mammogram
-to begin at diagnosis of LCIS or
ADH/ALH but not prior age 30 year
-Consider tomosynthesis
3.Annual breast MRI
-to begin at diagnosis of LCIS or
ADH/ALH but not prior age 25 year
4.risk reduction strategy
5.breast awareness

35.  Indication for genetic testing
 What is the screening guidelines

36.  1. Individuals with any blood relative with a known pathogenic/likely
pathogenic variant In a cancer susceptibility gene.
 2.Individuals meeting the criteria below but with previous limited testing
(eg, single gene and/or absent deletion duplication analysis) interested
in pursuing multi-gene testing
 3. Personal history of cancer- Breast cancer with at least one of the
following:
• Diagnosed at age 45 y; or
 Diagnosed at age 46-50 y with
 Unknown or limited family history; or
 A second breast cancer diagnosed at any age; or
 al close blood relative' with breast, ovarian, pancreatic, or high-grade (Gleason score 27) or
intraductal prostate cancer at any age
 Diagnosed at age < 60 y with triple-negative breast cancer;
 Diagnosed at any age with: Ashkenazi Jewish ancestry; or ≥ 1 close blood relative' with
breast cancer at age 50yr or ovarian, pancreatic, or metastatic or intraductal prostate
cancer at any age; or ≥ 3 total diagnoses of breast cancer in patient and/or close blood
relatives'


37.  Diagnosed at any age with male breast cancer
 Epithelial ovarian cancer (including fallopian tube cancer
or peritoneal cancer) at any age
 Exocrine pancreatic cancer at any age
 Metastatic or intraductal prostate cancer at any age
 High-grade (Gleason score 27) prostate cancer with:
Ashkenazi Jewish ancestry; or
 >1 close relatives with breast cancer at age 250 y or ovarian,
pancreatic, or metastatic or intraductal prostate cancer at any age: or
 ≥ 2 close relatives with breast or prostate cancer (any grade) at any age.
 A mutation identified on tumor genomic testing that has
clinical implications if also identified in the germline to aid
in systemic therapy decision-making, such as for HER2-
negative metastatic breast cancer.

38. 4.Family history of cancer
An affected or unaffected individual
with a first- or second-degree blood relative
meeting any of the criteria listed above
An affected or unaffected individual
who otherwise does not meet the criteria
above but has a probability >5% of BRCA1/2
pathogenic variant based on prior probability
models (eg. Tyrer-Cuzick, BRCAPro, Penn Ir

39. 5. Bilateral breast cancer, first diagnosed
between the ages of 50 and 65 y
An unaffected Ashkenazi Jewish individual.
An affected or unaffected individual who
otherwise does not meet any of tho above
criterla but with a 2.5%-5% probability
ofpathogenic variant based on prior
probability models (eg, Tyrer-Cuzick,
BRCAPro, Pennll

40.  Breast awareness starting at 18 year
 CBE every 6-12 month starting at age 21 year
 Breast screening
Age 20-29- annual MRI
Age 30-75-mammo or tomosynthesis
Age >75 individual basis
 Risk reduction startegy
 Genetic testing as advised

43.  4th most common intestinal malignancy
 Late diagnosis is very common
 Most are asymptomatic till late stage
 It is common and serious

44.  Recent NCCN Guidelines

45. In whom we will screen
Again it depends on risk factors not just ages
Risk assessment
AVERAGE RISK
INCREASED RISK
HIGH RISK

46. 1.Age more than 50 years(50-75 vs 75-86)
2.No history of adenoma or sessile serrated
polyp or colorectal carcinoma
3.No history of inflammatory bowel disease
4.Negative family history of CRC or confimred
advanced adenoma ( high grade dysplasia)
≥1cm , villous or tubulovillolus histology or
and advanced SSP (≥1cm, any dysplasia)

47.  Personal history of Adenoma or SSP
 Personal history of Colo rectal carcinoma
 IBD( Ulcerative colitis,crohns disease)
 Positive family history

48.  Lynch syndrome
 Polyposis syndrome
1.classical FAP
2.ATTENUATED FAP
3.MUTYH associated polyp
4.peutzh Jeghers syndrome
5.juvenile polyposis syndrome
6.serrated polyposis syndrome
7.Cowden syndrome
 Li fraumani syndrome

49.  Colonoscopy
 Guaic based test
 FIT
 DNA bases testing
 Ct colonography
 Sigmoidoscopy
DRE not help In screening but help to prevent
missed diagnosis

50.  colonoscopy remains the most accurate screening test for CRC at a single
application, Adequate colon preparation very important(split dose preparation vs
same day)
 Visualization should be up to ceacum
 Is inadequate preparation repeat in 1 year
 quality indicators of colonoscopy
ceacal intubation rate
adenoma detection rate
withdrawal time
 Sensitivity 72-86%
 recent studies have confirmed that colonoscopy misses polyps and may also miss
CRC
 Colonoscopy also presents a higher risk for harms than other tests.
 Patient discomfort

51.  screening with the FOBT involves a guaiac-based
test with dietary restriction
 immunochemical test without dietary restriction.
 Two samples from each of three consecutive
stools should be examined without rehydration.
 Patients with a positive test on any specimen
should be followed up with colonoscopy
 in the Minnesota trial, FOBT screening every other
year was found to reduce colorectal cancer
mortality by 21%
 High false +rate
 For distal colon lesions, FOBT may be less
sensitive

52.  The Faecal Immunochemical Test (FIT) uses
antibodies that specifically recognise human
haemoglobin (Hb).
 It means that a FIT result is not influenced by the
presence of other blood in stools, such as that
ingested through diet, compared to the guaiac
Faecal Occult Blood Test (gFOBT), therefore
reducing the chance of false positive results.
 Do not required bowel prepartaion
 FlexSure OBT/Hemoccult ICT is the only FIT that
is both FDA approved
 Not invasive and can detect entire colon

53.  Case–control studies have reported that
sigmoidoscopy is associated with reduced
mortality for colorectal carcinoma
 Colon carcinoma risk in the area beyond the
reach of the sigmoidoscope was not reduced

54.  Computed tomography colonography (CTC)—
“virtual colonoscopy”
 Bowel preparation required
 Sensitivity 80%
 CTC seems reasonable in patients with
incomplete colonoscopy or who are poor
candidates for colonoscopy.
 Colonoscopy required again if abnormality
detected
 HIGLHY OPERATOR DEPENDENT

56.  Sensitivity and specificity for fecal DNA testing
for colorectal cancer screening have recently
been reported as 87.5% and 82% respectively
 Such stool-based testing is appealing
because it is noninvasive, requires no special
colonic preparation, and has the capability of
detecting neoplasia throughout the entire
colon.
Under trial

57.  Not included in recent guidelines

63.  Mild risk- repeat colonoscopy in 3 yr
 High risk-repeat colonoscopy in 1 yr

65.  Amstredam and bethesda criteria

66.  NCCN recommends universal screening for
lynch syndrome of all CRC below 50
(previously it was 70)
 Pt with lynch syndrome should undergo
colonoscopy every 1-2 year sarting at age
20-25

68.  Children of an affected parent usually
undergo genetic testing at puberty and if
affected colonoscopy started at that time

69. THANK YOU