w



 

p The disease should be an important public health problem in
terms of its frequency and/or severity.
p The natural history of the disease presents a window of
opportunity for early detection. For cancer this generally refers to
a detectable preclinical phase (DPCP)
p An effective treatment should be available that favorably alters
the natural history of the disease. Usually for cancer this means a
reduction in cause-specific mortality.
p The treatment should be more effective if initiated during the
presymptomatic (or earlier) stage than during the symptomatic
(or later) stage
p A suitable screening test should be available, that is, one that is
accurate, acceptable to the population, fairly easy to administer,
safe, and relatively inexpensive
p There should be an appropriate screening strategy for the target
population
w


 
 
? The screening guidelines should be based on good scientific evidence (usually based on
results of a randomized controlled clinical trial) and economically feasible:
² Screening programs should have high rates of participation from the eligible
population.

² Screening programs for a particular geographic area should take into account
specific resources available for screening, diagnosis, and treatment so that countries
can focus on optimal recommendations based on available resources.

² Screening programs should be sensitive to patient and provider concerns.

² Screening programs should ensure prompt follow-up of positive tests with a

diagnostic examination and prompt treatment of cases.

² Screening programs should be cost-effective.

² Screening programs should be monitored and regularly evaluated.

 


 

 
 
 

.


p ›valuating Screening Tests
p Positive Predictive Value
p Test Sensitivity Versus Program Sensitivity
p Lead-Time Bias
p Overdiagnosis
› 
 


Ì à


    
  

÷ 
     
    


 

 


   
   
  

  !
 
ž  ž
%

ž 
p ˜ethods of Screening for CRC
p Fecal Occult Blood Testing
p Stool DNA Testing
p ›ndoscopy
p Rigid Proctoscopy/Sigmoidoscopy
p Flexible Sigmoidoscopy
p Colonoscopy
p Imaging Computed Tomography Colonography (Virtual
Colonoscopy)
p Other Imaging Technology [Capsule endoscopy (C›)]
p Double-contrast barium enema x-ray examination
ž    



    
‡   

%

ž 
j 
 
 


   
 


ž›jž
ž ž›j
p j


  
  

p Infection with the human papillomavirus (HPV)
p Age, race, and socioeconomic status
p Degree of immunosuppression (e.g., HIV positivity,
transplant patients)
p Sexual activity[*]
p Tobacco smoking

"Sexual behavior is probably largely a surrogate for the risk

of exposure to HPV.
ž 
ž
j 
 
 


 
 
 


ž   
 w

p A pap smear can reveal the presence of the human

papillomavirus: On the left, normal cells. On the right,
cells infected with the virus.
 j ž ž›j
w
w žj››% ‡› j

‡›.›ž. j j ž ž›j

p No good test for screening is currently available.

p Concentrate on those patients with familial or
heritable risk.
p Transvaginal ultrasonography and serum CA-125 are
worth doing for selected patients.

ž
÷j› .ž ž›j
p INDICATIONS FOR G›N›TIC T›STING IN BR›AST
CANC›R*
p A first-degree relative with breast cancer before age 40
p Two or more relatives with breast or ovarian cancer at
any age
p Three or more relatives with breast, ovarian, or colon
cancer at any age

* The indications for genetic testing in breast cancer and in other cancers are in
rapid evolution as the true risks become better defined and as prevention (e.g.,
tamoxifen) and early detection (e.g., mammography, ˜RI) strategies mature.
÷ ž
÷ ž
p Physical ›xamination
p Breast Self-›xamination
p ˜ammogram
p Nonmammographic Imaging Screening (magnetic
resonance imaging (˜RI) screening of women at risk
for familial breast cancer)
÷ ž
÷ ž
˜  
÷j› .˜j
wj. .›ž ž›j
p Screening and ›arly Detection
‡%.
j›ž.
›
˜
›‡j›ž.
wj. .›
.j %j w
 p w 

 j


  


Ultraviolet light (sun) exposure (cumulative)

%


ž ž›j ôeroderma pigmentosum

Nevoid basal cell syndrome


 
Skin complexion
Sunburn/tanning response
Degree of freckling
Premalignant dermatoses
Actinic (solar) keratoses
Leukoplakia
Chemical, thermal, and scar keratoses
Chronic inflammation
Immunosuppression
Prior history of skin cancer


Ultraviolet light exposure (intermittent)

%

˜elanocortin receptor variants
Atypical or dysplastic nevi
Dysplastic nevus syndrome


 
Less cutaneous pigmentation
ž ž›j
p US›FUL THINGS TO T›LL YOUR PATI›NTS ABOUT TH›
PR›V›NTION OF SKIN CANC›R
Ú Avoid sunburns (know your skin typeȄdo you burn
easily?).
Ú Avoid tanning booths.
Ú Use sunscreens with high SPF.
Ú Stay covered.[*]
Ú Avoid outdoor recreation between 10 am and 3 pm.
Ú ˜inimize sunlight exposure.
Ú Know your moles (and other skin lesions) and see a
dermatologist promptly if they change or are new.

p * A wet T-shirt has an SPF of 0; several companies now

make clothes that are specifically treated to give a high SPF.
ž ž›j 





 

p Screening and ›arly Detection
p the ABCD›s: asymmetry, border irregularity, color
variegation, and diameter (5 mm or greater), enlargement,
elevation
p prognostic factors that should be recorded: anatomic
location, ulceration, number of atypical lesions, presence of
lymph nodes
p type of biopsy: shave biopsy, incisional biopsy, excisional
biopsy, punch biopsy
p histologic criteria such as thickness (Breslow staging),
margins, ulceration, regression, satellitosis, angiolymphatic
invasion, mitotic activity, precursor lesions, host response,
and growth phase (radial vs. horizontal)
˜
%˜›
˜