the important of “ cancer screening” aumkhae sookprasert, md medicine department, kku
TRANSCRIPT
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The important of
“ Cancer Screening”
Aumkhae Sookprasert, MD
Medicine department, KKU
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Cancer Screening
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The most important end points for
cancer screening
Detect early stage case
Reduction in the incidence of advanced
case
Improve overall survival
Decreased overall and
specific mortality
Population based, RCT !
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Levels of Evidence in Cancer Screening
Decreased OS, DSMR in a well-performed RCT
Finding of decreased MR in internally controlled trials (but not RCT)
Finding of decreased MR from case cohort or case controlled observational studies
Results of multiple time series studies with or without intervention
Opinion of respected authorities or consensus reports of experts
* Cause-specific mortality is the 1o end point
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Potential “Bisases” of Screening
1. Selection bias
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Potential “Bisases” of Screening
2. Lead time bias
DeathControl
Screen
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Potential “Bisases” of Screening
3. Length bias
Indolent cancer, Pts with old age
“Overdiagnosis”
DeathControl Symptoms
Fast growing
Death rapidly
ScreenSlow growing, favorable prog
Asymptomatic+ Screening
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Harmful of Cancer Screening !!
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Levels of Evidence in Cancer Screening
Decreased OS, DSMR in a well-performed RCT
Finding of decreased MR in internally controlled trials (but not RCT)
Finding of decreased MR from case cohort or case controlled observational studies
Results of multiple time series studies with or without intervention
Opinion of respected authorities or consensus reports of experts
* Cause-specific mortality is the 1o end point
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Characteristic of “Good Cancer Screening test”
High sensitivity High specificity
Especially if it trigger invasive diagnostic procedures !!
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Standard Common
Cancer Screening &
Level of Evidence
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Breast Cancer
Breast Level of evidence
Comments
Age 40 – 49 yr
-Mammo+/-CBE 1 +RCT done in this subset of women
-BSE 5 RCT show inc biopsy rate without reduction of BC mortal
Age 50 – 69 yr
-Mammo+/-CBE 1 Benefits and harm are more favorable than younger women
-BSE 5 RCT show inc biopsy rate without reduction of BC mortal
Age 70+ yr - Not well represent in RCT, considered health and life expectancy
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Breast Cancer :How to screen effectively ?
5040 60
Mortality
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Breast Cancer :How to screen effectively ?
5040 60
Mortality
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Cervical Cancer
Cervix Level of evidenc
e
Comments
Pap Smear 3 Case control studies support utility of Pap smear, indirect evidence suggest benefit should be obtained by screening 3 yrs after sexual or by age 21 yr
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Cervical Cancer :How to screen effectively ?
5040 6021
3 yr
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Ovarian Cancer
Ovary Level of evidenc
e
Comments
CA 125
4, 5
Insufficient evidence of benefitPotential of HarmMost organization recommend against screening with both tool in general pop or women with history of affected family member
Transvaginal U/SX
X
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Prostate Cancer
Methods Level of evidence
Comments
PSA 5 Overdiagnosis is an issue
RCT are in progress
DRE 5 RCT are in progress
Transrectal
U/S
5 Lack of specificity !!X
X
X
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Testicular Cancer Screening!
Method Level of evidence
Comments
Palpation 5 Screening unlikely to benefit, Px success of advancedDisease rarity
X
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Colorectal Cancer
Methods Level of eviden
Comments
FOBT 1 Effective for aged >/= 50 yrs
(+ data in RCT)
Sigmoidoscope 3 + data from several case control study, start at age of 50 yrs
Colonoscope 5 No data
DC Barium Ene 5 No data
CT colonograp 5 Sens & specificity vary !
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Colorectal Cancer :How to screen effectively ?
5040 60
FOBT
q 3 yrs
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Lung Cancer Screening
Method Level of evidence
Comments
CXR -RCT show no benefit for CXR and cytology
Sputum cytology
-
Spiral CT - RCT are in progress
X
X?
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Leading cancers in Thailand (estimated), 1996
0 10 20 30 40
Leukaemia
Stomach
Skin & melanoma
Non - Hodgkin lymphoma
Bladder
Prostate
Oral cavity & pharynx
Colon & rectum
Lung
Liver
0 10 20 30
Leukaemia
Skin & melanoma
Thyroid
Oral - cavity & pharynx
Ovary
Colon & rectum
Lung
Liver
Breast
Cervix
ASR (World)ASR (World)
Male Female
37.6
25.9
10.8
6.8
4.8
4.6
4.9
4.2
4.1
3.9
19.5
17.2
16.0
10.0
7.3
5.2
4.8
3.6
3.6
3.5
Tumor registry report 2000 Courtsey from Dr Pisaln Mairiang.
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Liver cancers in different regions, 1995-1997
ASR (World) ASR (World)
Male Female
95.7
0 20 40 60 80 100
Songkhla
Bangkok
Khon Kaen
Lampang
Chiang Mai
Thailand
China, Qiding Country
0 20 40 60 80 100
Songkhla
Bangkok
Khon Kaen
Lampang
Chiang Mai
Thailand
Thailand, Khon Kaen
37.6
18.4
28.7
85.0
14.4
5.7
35.4
16.0
7.5
12.4
32.7
3.9
1.4
Tumor registry report 2000 Courtsey from Dr Pisaln Mairiang.
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Tumor Registry
Cancer Unit, Khon-kaen
University
Statistical Report2003
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Number of cancer cases by type of patients
Type of patients Number of cases
Total No of OPD 439,662
Total No of new patients 43,564
Total No of new malignancies
4,049
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5 Leading sites of cancer in both sexes
1. Liver and bile ducts : 1,186 29.3%
2. Bronchus and Lung : 368 9.1 %
3. Cervix uteri : 337 8.3 %
4. Breast : 192 4.7 %
5. Lymph nodes : 184 4.5 %
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Hepato-biliary : 39.5%
Bronchus & lung
: 12.6%
Lymph nodes
: 5.2%
Leukemia : 4.6%
Nasopharyngeal
: 3.4%
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Hepato-biliary : 39.5%
Cervical : 17%
Breast : 9.6%
Thyroid gland : 6,8%
Bronchus & lung
: 12.6%
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HCC & Gastric CA screening
Method Level of evidence
Comments
HCC- APF,U/S
- One RCT in China benefit, but had serious problem and inference to US pop uncertain !
Gastric- Scope
- Good evidence that scope in US pop not dec mortality,Data on higher risk uncetain
X
X
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RCT of screening for HCC
Zhang B, Yang B, Tang Z et al. J Cancer Res Clin Oncol 2004
19,200 : 35-59 yr + HBV markers
Chronic hepatitis
RScreen gr
(9757)Control (9443)
Participate (9373)
Not told, No screen
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Zhang B, Yang B, Tang Z et al. J Cancer Res Clin Oncol 2004
Screen gr (9757)
19,200 : 35-59 yr + HBV markers
Chronic hepatitis
R
Control (9443)
Participate (9373)
Not told, No screenAFP, U/S
q 6 mo
Recruited
1993 - 1995
End of study at 1997
- At least 5-7 times screening
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Screen gr (9757)
19,200 : 35-59 yr + HBV markers
Chronic hepatitis
R
Control (9443)
Participate (9373)
AFP, U/S q 6 mo
Recruited
1993 - 1995
1st screen + HCC
- 17 pts (0.18%)
By the end (1997)
- 69 pts (0.73)
December 1997
- 32 dies from HCC
Not told, No screen
67 pts with HCC
54 dies from HCC
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Incidence of HCC between screening & control
279.3 : 100,000
267 : 100,000
(268 : 100,000)
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Stage distribution
Stage Screen gr Control gr
Stage I 52 (60.5%) 0
Stage II 12 (13.9%) 25 (37.3%)
Stage III 22 (25.6%) 42 (62.7%)
Small HCC 39 (45.3%) 0
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Treatment modality
Treatment Screen gr Control gr
Resection 40 (46.5%) 5 (7.5%)
TACE/PEI 28 (32.6%) 28 (41.8%)
Conservative 18 (20.9% 34 (50.7%)
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Disease specific end points : Death from HCC
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How can we make a conclusion ?
5035 59
+ HBV
CAH
q 6 Months !
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Cholangiocarcinoma (CHCA)
Courtsey from Dr Pisaln Mairiang.
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CT SCAN
Courtsey from Dr Pisaln Mairiang.
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ERCP
Courtsey from Dr Pisaln Mairiang.
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Ultrasonography
Courtsey from Dr Pisaln Mairiang.
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Surgery is the only
chance for cure !
Any methods should we used to detect early cancer ?
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Etiology
• Infection:Opisthorchis viverrini, Clonorchis sinensis• Inflammatory bowel disease and Primary sclerosing cholangitis• Chemical exposures: Thorium dioxide, rubber and wood industry• Congenital diseases: Choledochal cyst and Caroli disease• Other: Ductal adenoma, biliary papillomatosis and alpha1-antitrysin deficiency
Courtsey from Dr Pisaln Mairiang.
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Stool exam
U/S
CT
ERCP
MRCP
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Stool exam
Prevalence : 24.5%
Incidence of CHCA in age > 35
= 93 – 317 / 100,000
= 0.0009 – 0.003
With highest prevalence
1 CHCA : 3,333
¼ U/S : 833
With Lowest prevalence
1 CHCA : 111,111
¼ U/S : 27,777
Sriumporn S, Pisani P et al. Trop Med Int Health 2004
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No effective screening
for CHCA !!
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Conclusion
Mammo,CBE
q 1 yr, >/= 40
Breast
Cervical
PAP q 1 x 3
>/= 21 yrs
AFP,U/S q 6 mo
>/= 35 yrs
HCC (high risk gr)
FOBT q 1 yr
>/= 50 yrs
Colon
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Conclusion
AFP,U/S q 6 mo
>/= 35 yrs
HCC (high risk gr)
FOBT q 1 yr
>/= 50 yrs
Colon