Preventive Medicine: Cancer Screening

 

#PreventiveMedicine

Cancer Screening:

Generally speaking, cancers are a major cause for death globally. It is a feared word. When heard, it feels like a death sentence or the end of the world. 

There is much ignorance about cancers in general.

I will address a few myths and misunderstandings today.

First of all not all cancers are equal in the way they behave, advance or cause suffering. Treatments vary depending on the tissue/ organ where cancer occurs, how early or late it is detected, how aggressive it is, how the general health of the person is at time of diagnosis etc.

Cancers do not necessarily mean a death sentence. There are cancers if detected very early can be removed with minor procedures and not always need additional chemotherapy or radiation. These patients live a normal life after removal of the cancer.

Not all cancers have screening tests to detect them early. But those that have effective screening tests have shown definite decrease in morbidity and mortality in those that undergo these screening tests.

Often times people avoid going for these tests because they are scared to find out they may have cancer. Not doing the test is not going to stop cancer. But if you allow these tests to find the cancer in early stages your life could be saved. So truly you should be scared of not getting the tests done regularly per established guidelines.

In the USA screening is routinely performed for four different cancers namely Breast cancer, cervical cancer, colon cancer and lung cancer.

These guidelines are applicable to people who have no personal or family history of cancer. 

Those with any history of cancer would have different recommendations and guidelines. Best to talk to your doctors about them. 

Colon Cancer:

Currently colon cancer screening is recommended to start at age 45 and till age 75 for people without a family history for this cancer. You may ask for a colonoscopy OR a simple stool test ( checking poop for microscopic blood). Each test has its pros and cons. 

Colonoscopy is the gold standard because it involves actually going into the colon and looking for cancer lesions with a camera. If any suspicious sites are seen, a biopsy can be taken right there. If that sample tissue confirms cancer, a smaller surgery can potentially cure the cancer because it is found before spreading elsewhere.

Colonoscopy is however an invasive procedure and may cost more if you don’t have insurance. You must be on a liquid diet for 2 days and are given medication to cleanse out the colon. This is not a very pleasing situation. The person is too weak and needs a driver both ways. If the colon is not cleaned out adequately sometimes the colonoscopy will need to be repeated. Gets frustrating. Though the specialists are trained and experienced the procedure has a potential for risks like introducing infection or causing trauma because you are inserting a tube with a camera through the rectum. 

If however all goes well and everything inside is found to be normal then you will need another colonoscopy only after 10 years. 

The other option which is the stool test is much simpler, non invasive and less expensive. You are given a small tube with a stick attached to its lid. You take a small sample of your poop with that stick and put into the tube and secure the lid. Bring it to the lab and they process it for microscopic quantities of blood that normally you would not see with the naked eye. If the test is positive for blood then go for colonoscopy to find where that blood is coming from. Rule out cancer as a source. If the initial stool test is negative, repeat the test next year. Year after year from age 45 to 75. 

Cervical Cancer:

Cervical cancer is unique in the sense it is not genetic. There is no family risk from one generation to next. It is caused by an infection by a virus. The Human Papilloma Virus. This virus is acquired through sexual contact. Men can pass the infection to women who in turn can get cervical cancer. Men can get oral cancer from the infection.

In 2006 a breakthrough was made in the scientific world by introduction of a vaccine against this virus. It is known as the HPV vaccine. The target population for this is from age 9 till age 45. It is most effective if given before one is exposed to the virus. Hence before becoming sexually active it has most value. Two doses of the vaccine six months apart is the schedule for people under age fifteen. Above fifteen three doses are recommended. The vaccine is a means of primary prevention because it is protects you are against infection from the virus.

There is another level of prevention called secondary prevention where a person may be already exposed to the virus but regular screening can detect early damage caused by the infection.

Women age 21 to 65 are recommended to get papsmears to screen for cervical cancer. 

For women 21-30, papsmears are recommended every 3 years. After 30, they are given HPV test if the HPV test is normal it can be repeated every 5 years until age 65. You may be called for additional testing like cytology and/or colposcopy if the initial test is not normal.

In India due to the greater population and cost constraints a very effective alternative initial screening test is employed instead of papsmear. It is called VIA or Visualization in Acetic Acid. Those women who show abnormality on this test are subjected to further testing with HPV, cytology etc. These tests are offered free of charge at government health clinics. I encourage you to spread the word to your loved ones and make use of these tests. 

Papsmears do NOT screen for uterine or vaginal cancers. If you are post menopausal and having new onset vaginal bleeding and got a normal papsmear you need additional testing with ultrasound and endometrial biopsy which can be done outpatient ( without hospital admission or general anesthesia). Talk to a good gynecologist if you are in such situation.

Breast cancer:

For some reason incidence of Breast cancer is on the rise around the world. Even without a family history more women are being found to have this cancer. Also at much younger ages.

The available cancer screening for women to detect breast cancer is mammogram. You may start it at 40 and get it every 1-2 years. A self breast exam regularly each month along with a yearly clinical breast exam from your doctor is highly recommended. Mammograms are recommended till age 80, or at least 75.

Lung cancer:

Primary prevention for lung cancer is to counsel people not to use tobacco and help them stop the habit. Various medications are available for de addiction from tobacco. Most effective strategy is one’s own will. 

Secondary prevention is when you have already exposed yourself to tobacco and are in the high risk category.

For people with significant history of smoking there are guidelines for lung cancer screening with CT scan of chest once a year. Those who have smoked equivalent of 1 pack of cigarettes daily for 30 years and actively smoking or who quit the habit less than 15 years back and are in the age group of 55 to 80 are eligible for this screening.

Most other cancers like ovarian cancer, uterine cancer, pancreatic cancer, stomach cancer, kidney or urinary bladder cancers, brain cancers do not have screening tests on a larger population basis. Those with family members with these cancers should speak to their doctors regarding their risk and potential testing, genetic counseling etc. These cancers are managed on individual basis depending on symptoms or history.

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