Cancer Screening

Screening recommendations for individual patients vary according to their level of risk with higher risk patients requiring more frequent and sometimes more invasive management. Risk is not static and may change over time based on changes in both family and medical history.

Breast Cancer

Women at all risk levels should practice the following preventative behaviors:

  • Breast self-awareness
  • Healthy lifestyle
  • Clinical breast exam
  • Mammogram

Clinical breast exams and mammograms should be performed at different intervals depending on risk level, as indicated below. Guidelines change frequently and may differ. Please refer to guidelines for most recent information.     

Average Risk               

  • Clinical breast exam: every 1-3 years beginning at age 25
  • Mammogram: at least every 2 years for ages 50-74; shared decision making for ages 40-49

Increased (Moderate) Risk                             

  • Clinical breast exam: annual or semi-annual from age 25
  • Mammogram: annual from age 40 or 10 years before earliest family diagnosis
  • Consider cancer genetic counseling
  • Breast MRI at age 25, if lifetime risk is >20%     
  • Consider chemoprevention, such as Tamoxifen 

High (Strong) Risk

  • Clinical breast exam: annual or semi-annual from age 25
  • Mammogram: annual from age 25-30 or 10 years before earliest family diagnosis
  • Cancer genetic counseling
  • Breast MRI: annual from age 25-30 or 10 years before earliest family diagnosis
  • Consider chemoprevention, such as Tamoxifen 
  • Consider prophylactic mastectomy

References

American Cancer Society (2007): ACS guidelines for breast screening with MRI as an adjunct to mammography.

American College of Physicians (2007): Screening mammography for Women 40 to 49 years of age: A Clinical Practice Guideline from the ACP.

National Comprehensive Cancer Network Breast cancer screening and diagnosis (2016), Breast cancer risk reduction (2017), and Genetic/familial high risk assessment: Breast and ovarian (2017). (Free registration required for access).

 

Ovarian Cancer

Women at all risk levels should practice the following preventative behaviors:

  • Ovarian cancer symptom awareness

Average Risk              

  • No current recommendations

Increased (Moderate) Risk                             

  • Consider chemoprevention, such as oral contraceptives
  • Consider cancer genetic counseling

High (Strong) risk

  • Consider chemoprevention, such as oral contraceptives
  • Prophylactic bilateral salpingo-oophorectomy (BSO): Ideally between 35-40 and upon completion of childbearing. (Note: Salpingectomy alone is not the standard of care for risk-reduction although clinical trials are ongoing)
  • While not recommended, clinicians and patients may consider ovarian cancer screening via CA-125 and/or transvaginal ultrasound every 6 months from age 30 or 5-10 years before earliest family diagnosis if BSO not performed
  • Cancer genetic counseling

References

National Comprehensive Cancer Network (2017): Genetic/familial high risk assessment: Breast and ovarian. (Free registration required for access).

 

Colorectal Cancer

Average Risk

  • Periodic (usually every 10 years) colonoscopy according to recognized guidelines
  • Other screening as recommended by recognized guidelines
  • Advise that specific lifestyle changes may modify the risk for cancer

Increased (Moderate) Risk

  • Colonoscopy at earlier ages/more frequent intervals than average risk individuals (dependent on family/medical history and polyp burden)
  • Regular updates of family history are important (diagnosis of colon or a Lynch-related cancer in one or more family members may change risk category)
  • Advise that specific lifestyle changes may modify the risk for cancer
  • Consider cancer genetic counseling

High (Strong) Risk

  • More intensive and frequent colonoscopy and screening for other related cancers (often annually)
  • Prophylactic surgery as an option for risk reduction
  • Participation in clinical trials
  • Examinations to detect other manifestations of the hereditary syndrome
  • Cancer genetic counseling

References

American Cancer Society, US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology (2008): Screening and Surveillance for the Early Detection of Colorectal Cancer and Adenomatous Polyps.

American College of Gastroenterology (2015): Clinical Guideline on Genetic Testing and Management of Hereditary Gastrointestinal Cancer Syndromes.

American College of Physicians (2012): Screening for Colorectal Cancer.

National Comprehensive Cancer Network (2016): Genetic/Familial High Risk Assessment: Colorectal. (Free registration required for access.)

 

Prostate Cancer

Many professional societies and others have developed guidelines about the routine use of PSA and digital rectal exam (DRE) for prostate cancer screening. The information below provides a summary of the recommendations as is relevant to different risk levels. The National Guidelines Clearinghouse has developed a guideline comparison document. The majority of guidelines support facilitating informed decision making about whether to pursue PSA and/or DRE by discussing the benefits and limitations.

Average Risk

Asymptomatic men with a life expectancy of at least 10 years with average risk should receive information about the benefits and risks of prostate cancer screening starting at age 50 years.

Increased (Moderate) Risk

Only ACP separates out individuals at increased risk from those at high risk. They define increased risk as African-American men and men with a first-degree relative diagnosed with prostate cancer, especially before age 65 years. ACP recommends that providers give these individuals information about uncertainties, risks and benefits of prostate cancer screening starting at age 45 years.

High (Strong) Risk

ACP and ACS define men at high-risk as those with multiple family members diagnosed with prostate cancer before age 65. They recommend starting the discussion at age 40 years. Other groups recommend 40 years as the start of the discussion, but also include in this group African-American men, those with a positive family history, and men taking 5-alpha-reductase inhibitors. NCCN specifies specific follow-up guidelines for these individuals based on PSA levels – annual PSA and DRE for PSA >1.0 and repeat PSA/DRE at 45 if PSA ≤ 1.0.

References

American College of Physicians (2013): Screening for Prostate Cancer.

National Guideline Clearinghouse (2015): Screening for Prostate Cancer Guideline Synthesis.