Study Points

Cancer Screening

Course #91992 - $40 • 10 Hours/Credits

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  1. Which of the following represents the standard criterion for the effectiveness of cancer screening?

    ISSUES IN CANCER SCREENING

    Early detection and treatment offer potential benefits of reduced morbidity and longer survival; however, these benefits alone do not define a cancer screening test as effective. Rather, the standard criterion for effective screening is evidence of a decrease in cause-specific mortality in randomized controlled trials [9]. This definition of efficacy is often misunderstood by the general public as well as by clinicians, who may consider screening to be effective if it increases early detection and improves survival. This misinterpretation was demonstrated in a study of clinicians' understanding of screening in which more than 300 primary care physicians were presented with scenarios about the effect of two hypothetical screening tests. In that study, significantly more physicians said they would recommend a screening test associated with an increase in five-year survival from 68% to 99% compared with a screening test associated with a decrease in cancer mortality from 2 to 1.6 per 1,000 persons (69% vs. 23%) [10]. Nearly half (47%) of the physicians said that detecting more cases of cancer in a screened population than an unscreened one was proof that screening saves lives.

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  2. A meta-analysis showed that which of the following was the barrier to screening most often cited by patients?

    ISSUES IN CANCER SCREENING

    Patient-related factors have included race/ethnicity, attitude toward screening, obesity, education level, income level, level of trust, access to health care, and availability of health insurance [6,7,12,14,20,21,22,23]. Lack of healthcare professional recommendation has also been a barrier noted by patients, with one meta-analysis showing that it was the most often cited barrier [24,25]. This finding highlights the importance of clinicians enhancing their adherence to guidelines and recommending appropriate screening to their patients.

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  3. Of the following, overdiagnosis has been most often associated with

    ISSUES IN CANCER SCREENING

    Overdiagnosis has been associated most often with breast, prostate, and lung cancer. There is little evidence of overdiagnosis with screening for either cervical or colorectal cancer (with conventional methods), because the rate of diagnosis of both cancers is decreasing [50].

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  4. Which of the following recommendations adheres to most screening guidelines for a 30-year-old asymptomatic woman at average risk for breast cancer?

    BREAST CANCER

    RECOMMENDATIONS FOR BREAST CANCER SCREENING FOR AVERAGE-RISK WOMEN

    Organization (Year) Screening Recommendations
    Imaging Clinical Breast Exam Self-Exam
    U.S. Preventive Services Task Force (2016)
    Age 50 to 74 years: Biennial mammography
    Age ≥75 years: Evidence is insufficient to assess benefits and harms
    Not addressedAwareness of breast changes; discuss changes with physician
    American College of Physicians (2019)
    Age 40 to 49 years: Individualized assessment of risk for discussion of benefits and harms of screening mammography, as well as woman's preferences
    Age 50 to 74 years: Offer biennial mammography
    Age 75 and older or life expectancy less than 10 years: Do not screen.
    Do not useNot addressed
    American Cancer Society (2015)
    Age 45 to 54 years: Annual mammography (40 to 44 years, optional)
    Age 55 years and older: Biennial screening (annual optional)
    Less than 10 year life expectancy: No screening
    Not recommendedNot recommended
    National Comprehensive Cancer Network (2019)Age ≥40 years: Annual mammography
    Age ≥25 years but <40 years: Every 1 to 3 years
    Age ≥40 years: Annually
    Breast awareness
    American College of Obstetrics and Gynecology (2017, 2019 guidance statement)
    Age 40 to 49 years: Individualized assessment of risk; discussion of benefits/harms of screening mammography and woman's preferences.
    Age 50 to 74 years: Biennial screening
    Age 75 years and older: No screening in patient with less than 10-year life expectancy
    Do not useNot addressed
    Society of Breast Imaging/American College of Radiology (2010)Age ≥40 years: Annual mammography; end screening when life expectancy is <5 to 7 yearsNot addressedNot addressed
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  5. Which of the following breast cancer screening recommendations is guideline consistent for an asymptomatic woman 54 years of age with average risk?

    BREAST CANCER

    The National Comprehensive Cancer Network (NCCN) and the Society of Breast Imaging/American College of Radiology (SBI/ACR) recommend screening mammography beginning at 40 years of age for women with average risk for the disease and no symptoms [54,56]. The American College of Physicians (ACP) and the American College of Obstetrics and Gynecology (ACOG) determined that clinicians should discuss the potential benefits and harms of screening mammography with women 40 to 49 years of age and base decisions about screening on these benefits and harms, as well as on a woman's preferences and breast cancer risk profile [55,58]. Physicians should order biennial mammography screening if an informed woman requests it.

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  6. The breast cancer screening method recommended in all guidelines is

    BREAST CANCER

    Digital mammography has nearly entirely replaced film mammography in the United States and is the screening method recommended in all guidelines [54,55,56,57,58,59,60]. Meta-analyses of large randomized trials have shown that the detection rate is slightly higher for digital mammography compared with film mammography. However, data on the benefit of digital mammography have been conflicting. In one meta-analysis, the higher detection rate was found primarily among women 60 years of age and older, whereas in another, the detection rate was higher among women younger than 50 years of age [65,66]. The NCCN notes that digital mammography appears to most benefit young women and women with dense breasts [54].

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  7. A woman is 38 years of age and has a five-year risk of breast cancer of 1.8% according to the modified Gail model. Which of the following screening recommendations is guideline consistent?

    BREAST CANCER

    BREAST CANCER SCREENING OR SURVEILLANCE ACCORDING TO HIGH-RISK FACTORS

    Risk Factor Recommendation for Screening
    NCCN SBI/ACR
    Age 35 years or older and five-year risk of invasive breast cancer of 1.7% or more according to the modified Gail model
    Annual digital mammography plus clinical breast examination every 6 to 12 months
    Breast awareness
    Lifetime risk of more than 20% according to risk models that rely primarily on family history
    Annual digital mammography plus clinical breast examination every 6 to 12 months beginning 10 years before youngest affected family member (but not younger than 30 years of age) and annual breast MRI beginning at same time.
    Referral to genetic counseling
    Breast awareness
    Annual mammography and MRI by 30 years of age but not before 25 years of age) or 10 years before age of youngest affected family member
    Radiation therapy (RT) to the chest at a younger age (10 to 30 years)
    Women <25 years of age: Annual clinical breast examination beginning 10 years after RT
    Women ≥25 years of age: Annual digital mammography plus clinical breast examination every 6 to 12 months beginning 10 years after RT but not prior to 30 years of age and recommended annual breast MRI 10 years after RT but not prior to 25 years of age
    Breast awareness
    Annual mammography and MRI beginning 8 years after RT; mammography before 25 years of age is not recommended
    Lifetime risk of more than 20% based on history of lobular carcinoma in situ or ADH/ALH
    Annual digital mammography plus clinical breast examination every 6 to 12 months beginning at the time of diagnosis but not less than 30 years of age
    Consider annual MRI
    Breast awareness
    Annual mammography from time of diagnosis; annual MRI may also be considered
    Personal history of breast cancerAnnual digital mammography and history and physical examination every 4 to 6 months for 5 years, then every 12 monthsAnnual mammography from time of diagnosis; either annual MRI or ultrasound may be considered
    Suggested or known hereditary breast and ovarian cancer syndrome (BRCA1 or BRCA2 mutations)
    Women: Annual MRI with contrast (preferred) or mammography (if MRI unavailable) at 25 to 29 years of age—may individualize the starting age based on family history if breast cancer diagnosis under 30 years of age is present
    Annual mammography and MRI with contrast at 30 to 75 years of age
    Consider screening on an individual basis after 75 years of age
    Clinical breast examination every 6 to 12 months starting at 25 years of age
    Breast awareness starting at 18 years of age
    Annual mammography and MRI beginning at 30 years of age but not before 25 years of age
    Men: Clinical breast examination every 12 months starting at 35 years of age
    Breast self-exam starting at 35 years of age
    Peutz-Jeghers syndromeAnnual mammography and MRI plus clinical breast examination every 6 months beginning around 25 years of age
    Lynch syndromeOptimal screening strategy uncertain
    Cowden syndrome
    Annual mammography and breast MRI starting at 30 to 35 years of age or 5 to 10 years before the earliest known breast cancer in the family (whichever comes first)
    Clinical breast examination every 6 to 12 months starting at 25 years of age or 5 to 10 years before the earliest known breast cancer in the family (whichever comes first)
    Breast awareness starting at 18 years of age
    Li-Fraumeni syndrome
    Annual breast MRI with contrast (preferred) or mammography and starting at 20 to 29 years of age (or individualized based on earliest age of onset in family)
    Annual mammography and breast MRI at 30 to 75 years of age
    Clinical breast examination every 6 to 12 months starting at 20 to 25 years of age or 5 to 10 years before the earliest known breast cancer in the family if before 20 years (whichever comes first)
    Breast awareness starting at 18 years of age
    ADH = atypical ductal hyperplasia, ALH = atypical lobular hyperplasia, NCCN = National Comprehensive Cancer Network, SBI/ACR = Society of Breast Imaging/American College of Radiology.
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  8. According to a meta-analysis, screening mammography leads to the greatest reduction in breast cancer-related mortality among which of the following age-groups?

    BREAST CANCER

    A meta-analysis done as part of the USPSTF literature review showed that reductions in mortality differ among age-groups. Screening with mammography reduced breast cancer-related mortality by 15% for women 39 to 49 years of age, by 14% for women 50 to 59 years of age, and by 32% for women 60 to 69 years of age [94]. Investigators conducting a Cochrane review also found that screening was associated with a significant reduction in mortality but that screening had no effect on mortality when only trials with adequate randomization were considered [95]. These authors estimated that screening reduced mortality by approximately 15%, but with an absolute reduction of about 0.05% per year for a woman of average risk [95]. The Cochrane review excluded observational studies, which have shown a positive effect of mammography [69].

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  9. Of the following, performance of a biopsy based on the findings of screening mammography is most likely for a woman who is

    BREAST CANCER

    Mammographic findings also commonly lead to additional procedures. Additional imaging is done in 56.3 to 84.3 women per 1,000 screened, with the highest rate among women 40 to 49 years of age [94]. The rate of biopsy is lower, ranging from 12.2 per 1,000 screened for women 70 to 79 years of age to 9.3 per 1,000 screened for women 40 to 49 years of age. An estimated 47 women per 1,000 screened 40 to 49 years of age will have additional imaging to diagnose one case of invasive breast cancer, and an estimated five women per 1,000 screened of the same age will have a biopsy to diagnose one case of invasive breast cancer [94]. These numbers are lower for other age-groups, ranging from eight to 22 per 1,000 screened for additional imaging and 1.5 to three per 1,000 screened for biopsy [94].

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  10. Which of the following cervical cancer screening recommendations is guideline consistent for an asymptomatic woman who is 25 years of age?

    CERVICAL CANCER

    RECOMMENDATIONS FOR CERVICAL CANCER SCREENING FOR AVERAGE-RISK WOMEN

    Screening Factor USPSTF ACS/ASCCP/ASCP
    Starting age21 years21 years
    Ending age65 years if prior screenings are negative within past 10 yearsa65 years if prior screenings are negative within past 10 yearsa and if there has been no history of CIN2+ within the past 20 years
    Screening method
    Age 21 to 29 years: Cytology (Pap test) alone
    Age 30 to 65 years: Cytology alone, hrHPV testing alone, or cytology plus hrHPV testing
    Age 21 to 29 years: Cytology (Pap test) alone
    Age 30 to 65 years: Cytology plus HPV testing (preferred) or cytology alone
    Screening interval
    Age 21 to 29 years: Every 3 years
    Age 30 to 65 years: Every 3 years for cytology alone; every 5 years for hrHPV testing alone; every 5 years for cytology plus hrHPV testing
    Age 21 to 29 years: Every 3 years
    Age 30 to 65 years: Every 3 years for cytology alone; every 5 years for cytology plus HPV testing
    ACS/ASCCP/ASCP = American Cancer Society/American Society for Colposcopy and Cervical Pathology/American Society for Clinical Pathology, CIN2+ = cervical intraepithelial neoplasia of grade 2 or higher, hrHPV = high risk human papillomavirus, Pap = Papanicolaou, USPSTF = U.S. Preventive Services Task Force.
    aAdequate prior screening is defined as three consecutive negative cytology results (or two consecutive negative co-testing results) within the past 10 years, with the most recent test occurring within the past 5 years.
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  11. The preferred cervical cancer screening recommendation for an asymptomatic woman who is 45 years of age is

    CERVICAL CANCER

    RECOMMENDATIONS FOR CERVICAL CANCER SCREENING FOR AVERAGE-RISK WOMEN

    Screening Factor USPSTF ACS/ASCCP/ASCP
    Starting age21 years21 years
    Ending age65 years if prior screenings are negative within past 10 yearsa65 years if prior screenings are negative within past 10 yearsa and if there has been no history of CIN2+ within the past 20 years
    Screening method
    Age 21 to 29 years: Cytology (Pap test) alone
    Age 30 to 65 years: Cytology alone, hrHPV testing alone, or cytology plus hrHPV testing
    Age 21 to 29 years: Cytology (Pap test) alone
    Age 30 to 65 years: Cytology plus HPV testing (preferred) or cytology alone
    Screening interval
    Age 21 to 29 years: Every 3 years
    Age 30 to 65 years: Every 3 years for cytology alone; every 5 years for hrHPV testing alone; every 5 years for cytology plus hrHPV testing
    Age 21 to 29 years: Every 3 years
    Age 30 to 65 years: Every 3 years for cytology alone; every 5 years for cytology plus HPV testing
    ACS/ASCCP/ASCP = American Cancer Society/American Society for Colposcopy and Cervical Pathology/American Society for Clinical Pathology, CIN2+ = cervical intraepithelial neoplasia of grade 2 or higher, hrHPV = high risk human papillomavirus, Pap = Papanicolaou, USPSTF = U.S. Preventive Services Task Force.
    aAdequate prior screening is defined as three consecutive negative cytology results (or two consecutive negative co-testing results) within the past 10 years, with the most recent test occurring within the past 5 years.
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  12. According to established guidelines, cervical cancer screening should begin at

    CERVICAL CANCER

    The USPSTF and the ACS/ASCCP/ASCP recommend that cervical screening should begin at 21 years of age [104,105]. This age was established because studies showed that screening of women in their teens was associated with few detected cases of cancer and a high number of false-positive test results [106]. Screening is not recommended for women younger than 21 years of age regardless of the age at which sexual activity began or of other risk factors [104].

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  13. Which of the following cervical cancer screening recommendations is guideline consistent for an asymptomatic woman, 67 years of age, who has had negative results on three consecutive Pap tests within the past 10 years?

    CERVICAL CANCER

    The USPSTF recommends the discontinuation of screening at 65 years of age for women who have had adequate prior screenings and are not otherwise at high risk for cervical cancer, as screening offers little to no benefit for women in this age-group [105]. Adequate prior screening is defined as three consecutive negative cytology results (or two consecutive negative co-testing results) within the past 10 years, with the most recent test occurring within the past 5 years. The recommendation in the ACS/ASCCP/ASCP guideline is similar, with the added note that screening can be discontinued after 65 years of age for women who have no history of cervical intraepithelial neoplasia grade 2 or higher within the past 20 years [104]. In addition, screening should not begin again in older women for any reason, including a new sexual partner.

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  14. A woman has a negative result on cytology testing and a positive result on HPV testing. Which of the following is the most appropriate next step?

    CERVICAL CANCER

    A positive HPV result with a negative cytology result occurs in approximately 11% of women 30 to 34 years of age and in 2.6% of women 60 to 65 years of age [108]. Direct referral for colposcopy should not be done for women who have a negative cytology result with a positive HPV result [104]. Instead, the ACS/ASCCP/ASCP guideline recommends that repeat co-testing be done in 12 months for women with these results. If either repeat test is positive, colposcopy is recommended; if both tests are negative, routine screening may be resumed [104]. Alternatively, women who have a negative cytology result and a positive HPV result may have HPV genotype-specific testing for HPV16 alone or for HPV16/18. Colposcopy is recommended if either test is positive; if testing results are negative, co-testing should be repeated in 12 months.

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  15. Which of the following cervical cancer screening recommendations is guideline consistent for a woman who is 35 years of age and receives chronic treatment with corticosteroids?

    CERVICAL CANCER

    The ACS recommends following guidelines of the U.S. Public Health Service and the Infectious Disease Society of America for screening of women with a compromised immune system [40]. These guidelines indicate that cervical screening be carried out twice within the first year after diagnosis or treatment and annually thereafter. As with women exposed to DES, there is no specific age at which to stop screening [40].

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  16. All guidelines recommend beginning colorectal cancer screening at what age for people at average risk for the disease?

    COLORECTAL CANCER

    All guidelines recommend beginning colorectal cancer screening at 50 years of age for people at average risk for the disease [113,115,116,117,118]. The 2009 update of the American College of Gastroenterology (ACG) guideline recommends that screening begin at 45 years of age for black individuals because of the higher incidence of colorectal cancer and related mortality in that population, as well as an earlier average age at the time of diagnosis [117].

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  17. Which of the following recommendations for colorectal cancer screening in average-risk individuals is consistent with guidelines?

    COLORECTAL CANCER

    RECOMMENDATIONS FOR COLORECTAL CANCER SCREENING FOR AVERAGE-RISK MEN AND WOMEN BEGINNING AT 50 YEARS OF AGE

    Screening Recommendation Notes
    Method Interval
    Flexible sigmoidoscopy5 yearsMay be performed alone or in conjunction with annual stool-based test
    Colonoscopy10 yearsRepeat in 5 years if polyps found
    CT colonography5 years
    Stool-based test (FOBT or FIT)1 yearMust have high sensitivity for detecting cancer
    Stool DNA test (sDNA)Uncertain
    Double-contrast barium enema5 yearsRecommended only in the ACS/USMSTF/ACR guideline
    CT = computed tomography, FIT = fecal immunohistochemical test, FOBT = fecal occult blood test.
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  18. An asymptomatic woman who is 36 years of age tells her primary care provider that early adenomas were found on colonoscopy in her father and older brother. Which of the following screening recommendations is guideline consistent for this patient?

    COLORECTAL CANCER

    RECOMMENDATIONS FOR COLORECTAL CANCER SCREENING FOR HIGH-RISK MEN AND WOMEN

    Risk FactorScreening Recommendations
    ACS/USMTF/ACRNCCNACG
    Family history
    One first-degree relative with colorectal cancer or advanced adenoma diagnosed before 60 years of age OR two first-degree relatives with colorectal cancer or advanced adenomaColonoscopy every 5 years beginning at 40 years of age, or 10 years younger than age at diagnosis of the youngest affected relativeColonoscopy every 5 years beginning at 40 years of age, or 10 years younger than age at diagnosis of the youngest affected relativeColonoscopy every 5 years beginning at 40 years of age, or 10 years younger than age at diagnosis of the youngest affected relative
    Second-degree relative with colorectal cancer diagnosed before 50 years of ageColonoscopy every 5 to 10 years beginning at 50 years of age
    Colorectal cancer or adenomatous polyps in first-degree relative diagnosed at 60 years of age or older OR in two second-degree relatives with colorectal cancerScreening options as for average-risk individuals, but beginning at 40 years of age
    Personal history
    Adenomatous polyp
    1 or 2 small tubular adenomas with low-grade dysplasia: Colonoscopy at 5 to 10 years
    3 to 10 adenomas or 1 adenoma >1 cm or any adenoma with villous features or high-grade dysplasia: Colonoscopy at 3 years
    Low-risk adenomatous polyps: Repeat colonoscopy within 5 years; if no polyps, repeat every 10 years
    Advanced or multiple adenomatous polyps: Repeat colonoscopy within 3 years; if no polyps, repeat within 5 years
    Inflammatory bowel disease, chronic ulcerative colitis, or Crohn diseaseColonoscopy every 1 to 2 years with biopsies for dysplasia, beginning 8 years after the onset of pancolitisColonoscopy every 1 to 2 years beginning 8 to 10 years after onset of symptoms of pancolitis
    Hereditary syndromes
    Lynch syndrome (MLH1 and MSH2 mutations)Colonoscopy every 1 to 2 years beginning at 20 to 25 years of age or 10 years younger than age at diagnosis of the youngest affected relativeColonoscopy every 1 to 2 years beginning at 20 to 25 years of age or 2 to 5 years younger than age at diagnosis of the youngest affected relative if diagnosed before 25 years of ageColonoscopy every 2 years beginning at 20 to 25 years of age and then annually after 40 years of age
    Juvenile polyposis syndromeColonoscopy every year if polyps found or every 2 to 3 years if no polyps found beginning around 15 years of age
    Peutz-Jeghers syndromeColonoscopy every 2 to 3 years beginning in the late teenage years
    ACG = American College of Gastroenterology, ACS/USMSTF/ACR = American Cancer Society/U.S. Multisociety Task Force on Colorectal Cancer/American College of Radiology, NCCN = National Comprehensive Cancer Network.
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  19. An asymptomatic woman who is 48 years of age tells her primary care provider that colorectal cancer was diagnosed in her sister at 58 years of age. No cancers have been diagnosed in any other family members. Which of the following colorectal cancer screening recommendations is guideline consistent?

    COLORECTAL CANCER

    RECOMMENDATIONS FOR COLORECTAL CANCER SCREENING FOR HIGH-RISK MEN AND WOMEN

    Risk FactorScreening Recommendations
    ACS/USMTF/ACRNCCNACG
    Family history
    One first-degree relative with colorectal cancer or advanced adenoma diagnosed before 60 years of age OR two first-degree relatives with colorectal cancer or advanced adenomaColonoscopy every 5 years beginning at 40 years of age, or 10 years younger than age at diagnosis of the youngest affected relativeColonoscopy every 5 years beginning at 40 years of age, or 10 years younger than age at diagnosis of the youngest affected relativeColonoscopy every 5 years beginning at 40 years of age, or 10 years younger than age at diagnosis of the youngest affected relative
    Second-degree relative with colorectal cancer diagnosed before 50 years of ageColonoscopy every 5 to 10 years beginning at 50 years of age
    Colorectal cancer or adenomatous polyps in first-degree relative diagnosed at 60 years of age or older OR in two second-degree relatives with colorectal cancerScreening options as for average-risk individuals, but beginning at 40 years of age
    Personal history
    Adenomatous polyp
    1 or 2 small tubular adenomas with low-grade dysplasia: Colonoscopy at 5 to 10 years
    3 to 10 adenomas or 1 adenoma >1 cm or any adenoma with villous features or high-grade dysplasia: Colonoscopy at 3 years
    Low-risk adenomatous polyps: Repeat colonoscopy within 5 years; if no polyps, repeat every 10 years
    Advanced or multiple adenomatous polyps: Repeat colonoscopy within 3 years; if no polyps, repeat within 5 years
    Inflammatory bowel disease, chronic ulcerative colitis, or Crohn diseaseColonoscopy every 1 to 2 years with biopsies for dysplasia, beginning 8 years after the onset of pancolitisColonoscopy every 1 to 2 years beginning 8 to 10 years after onset of symptoms of pancolitis
    Hereditary syndromes
    Lynch syndrome (MLH1 and MSH2 mutations)Colonoscopy every 1 to 2 years beginning at 20 to 25 years of age or 10 years younger than age at diagnosis of the youngest affected relativeColonoscopy every 1 to 2 years beginning at 20 to 25 years of age or 2 to 5 years younger than age at diagnosis of the youngest affected relative if diagnosed before 25 years of ageColonoscopy every 2 years beginning at 20 to 25 years of age and then annually after 40 years of age
    Juvenile polyposis syndromeColonoscopy every year if polyps found or every 2 to 3 years if no polyps found beginning around 15 years of age
    Peutz-Jeghers syndromeColonoscopy every 2 to 3 years beginning in the late teenage years
    ACG = American College of Gastroenterology, ACS/USMSTF/ACR = American Cancer Society/U.S. Multisociety Task Force on Colorectal Cancer/American College of Radiology, NCCN = National Comprehensive Cancer Network.
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  20. An asymptomatic man at average risk for colorectal cancer is found to have low-risk adenomatous polyps on sigmoidoscopy. Which of the following is the most appropriate next step?

    COLORECTAL CANCER

    RECOMMENDATIONS FOR COLORECTAL CANCER SCREENING FOR HIGH-RISK MEN AND WOMEN

    Risk FactorScreening Recommendations
    ACS/USMTF/ACRNCCNACG
    Family history
    One first-degree relative with colorectal cancer or advanced adenoma diagnosed before 60 years of age OR two first-degree relatives with colorectal cancer or advanced adenomaColonoscopy every 5 years beginning at 40 years of age, or 10 years younger than age at diagnosis of the youngest affected relativeColonoscopy every 5 years beginning at 40 years of age, or 10 years younger than age at diagnosis of the youngest affected relativeColonoscopy every 5 years beginning at 40 years of age, or 10 years younger than age at diagnosis of the youngest affected relative
    Second-degree relative with colorectal cancer diagnosed before 50 years of ageColonoscopy every 5 to 10 years beginning at 50 years of age
    Colorectal cancer or adenomatous polyps in first-degree relative diagnosed at 60 years of age or older OR in two second-degree relatives with colorectal cancerScreening options as for average-risk individuals, but beginning at 40 years of age
    Personal history
    Adenomatous polyp
    1 or 2 small tubular adenomas with low-grade dysplasia: Colonoscopy at 5 to 10 years
    3 to 10 adenomas or 1 adenoma >1 cm or any adenoma with villous features or high-grade dysplasia: Colonoscopy at 3 years
    Low-risk adenomatous polyps: Repeat colonoscopy within 5 years; if no polyps, repeat every 10 years
    Advanced or multiple adenomatous polyps: Repeat colonoscopy within 3 years; if no polyps, repeat within 5 years
    Inflammatory bowel disease, chronic ulcerative colitis, or Crohn diseaseColonoscopy every 1 to 2 years with biopsies for dysplasia, beginning 8 years after the onset of pancolitisColonoscopy every 1 to 2 years beginning 8 to 10 years after onset of symptoms of pancolitis
    Hereditary syndromes
    Lynch syndrome (MLH1 and MSH2 mutations)Colonoscopy every 1 to 2 years beginning at 20 to 25 years of age or 10 years younger than age at diagnosis of the youngest affected relativeColonoscopy every 1 to 2 years beginning at 20 to 25 years of age or 2 to 5 years younger than age at diagnosis of the youngest affected relative if diagnosed before 25 years of ageColonoscopy every 2 years beginning at 20 to 25 years of age and then annually after 40 years of age
    Juvenile polyposis syndromeColonoscopy every year if polyps found or every 2 to 3 years if no polyps found beginning around 15 years of age
    Peutz-Jeghers syndromeColonoscopy every 2 to 3 years beginning in the late teenage years
    ACG = American College of Gastroenterology, ACS/USMSTF/ACR = American Cancer Society/U.S. Multisociety Task Force on Colorectal Cancer/American College of Radiology, NCCN = National Comprehensive Cancer Network.
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  21. Which of the following colorectal screening tests has been associated with a reduction in colorectal cancer-specific mortality of more than 60%?

    COLORECTAL CANCER

    In a meta-analysis (nine studies), flexible sigmoidoscopy was associated with a 28% reduction in mortality compared with no screening [128]. Similar reviews have shown that FOBT (either annually or biennially) led to a 14% to 15% reduction in colorectal cancer-related mortality [128,131]. The positive impact of FOBT was supported by the results of long-term follow-up of more than 46,000 people (50 to 80 years of age) in the Minnesota Colon Cancer Control Study [44]. The participants in this study were randomly assigned to usual care (control) or to annual or biennial FOBT. Through 30 years of follow-up, screening reduced colorectal cancer-related mortality by 32% (annual screening) and 22% (biennial screening) compared with no screening. There was no reduction in all-cause mortality. The findings in this population suggest that the effect of screening persists after screening has stopped [132].

    Another large, long-term study provides evidence of the effect of endoscopic screening on mortality. In this study, nearly 89,000 participants in the Nurses' Health Study and the Health Professionals Follow-up Study were followed up for more than 22 years. Compared with no endoscopic screening, sigmoidoscopy and colonoscopy were associated with a lower incidence of distal colorectal cancer, and colonoscopy was associated with a modestly lower incidence of proximal colon cancer as well [45]. The total number of colorectal cancers diagnosed was 1,164 in the group that had no screening, 82 in the group that had endoscopic polypectomy, 348 in the group that had sigmoidoscopy, and 221 in the group that had colonoscopy. Multivariate analysis demonstrated that these data represent incidence reductions of 43%, 40%, and 56%, respectively. Both types of endoscopic screening were also associated with lower mortality. The number of deaths in the no-screening group was 349, compared with 73 and 52 in the sigmoidoscopy and colonoscopy groups, respectively. According to multivariate analysis, these data represent mortality reductions of 41% and 68%. An analysis of trends in the incidence of colorectal cancer and related mortality from 1975 to 2015 demonstrated an overall decrease in the incidence of colorectal cancer, with modeling estimating that half of the decline in mortality could be attributed to screening [133].

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  22. Guidelines for lung cancer screening recommend against screening for people

    LUNG CANCER

    Lung cancer screening is not recommended for asymptomatic persons with low or moderate risk for lung cancer. The definition of low or moderate risk differs slightly among guidelines. The NCCN guideline defines low risk as an age younger than 50 years and/or a history of smoking of less than 20 pack-years [143]. Moderate risk is defined as an age 50 years or older and a history of smoking or secondhand smoke exposure of 20 pack-years or more with no additional risk factors. The American College of Chest Physicians (ACCP) defines low or moderate risk as an age younger than 55 years, a history of smoking of fewer than 30 pack-years, or smoking cessation more than 15 years previously [144]. Guidelines also recommend against screening for people with severe comorbidities that would preclude potentially curative treatment and/or limit life expectancy [48,49,141,144].

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  23. Which of the following statements about lung cancer screening is TRUE?

    LUNG CANCER

    Lung cancer screening is not recommended for asymptomatic persons with low or moderate risk for lung cancer. The definition of low or moderate risk differs slightly among guidelines. The NCCN guideline defines low risk as an age younger than 50 years and/or a history of smoking of less than 20 pack-years [143]. Moderate risk is defined as an age 50 years or older and a history of smoking or secondhand smoke exposure of 20 pack-years or more with no additional risk factors. The American College of Chest Physicians (ACCP) defines low or moderate risk as an age younger than 55 years, a history of smoking of fewer than 30 pack-years, or smoking cessation more than 15 years previously [144]. Guidelines also recommend against screening for people with severe comorbidities that would preclude potentially curative treatment and/or limit life expectancy [48,49,141,144].

    High risk for lung cancer was defined in the largest randomized controlled trial of lung cancer screening trial in the United States to date (50,000 individuals), the NLST [48]. In that trial, high risk was based on patient age and smoking history (i.e., number of pack-years, smoking status, and time since smoking cessation), with the following criteria:

    • Age of 55 to 74 years

    • History of current or former smoking

    • Smoking history of at least 30 pack-years

    • Smoking cessation of fewer than 15 years for former smokers

    This definition of high risk is based on research showing that the incidence of lung cancer is relatively low before 50 years of age but increases with age, especially after the age of 60 years, and that age-specific incidence rates increase with cumulative exposure to tobacco smoke [141,143,145]. Guidelines have modeled the definition of high risk on these criteria. Analysis of data from 2010 has indicated that approximately 8.6 million people in the United States (5.2 million men and 3.4 million women) were eligible for lung cancer screening based on the NLST eligibility criteria [146]. However, this number represents only approximately 27% of all individuals in whom lung cancer is diagnosed in the United States [147]. Other risk models are being explored to determine if the inclusion of additional risk factors will help better select candidates for screening.

    The American Society of Clinical Oncology (ASCO), the NCCN, the ACS, and the ACCP, with input from the American Thoracic Society (ATS), collaborated on a literature review on lung cancer screening from which evidence-based guidelines were developed [49]. According to these guidelines, screening is recommended for individuals 55 to 74 years of age who are current or former smokers who have (or had) smoked for at least 30 pack-years and, if a former smoker, who has quit within the past 15 years [49]. Guidelines established individually by these organizations, as well as by the American Lung Association, define high risk similarly [143,144,148,149,150]. In its own guideline, the ATS notes that screening may begin at 50 years of age for individuals who have a 20 pack-year history of smoking and one additional comorbidity that results in a 5% cumulative risk of lung cancer developing over the next five years [151].

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  24. Which of the following was the most common harm associated with lung cancer screening in the National Lung Screening Trial?

    LUNG CANCER

    Rates of false-positive results with LDCT screening are high. Overall, studies have shown that screening with LDCT has identified small nodules in 10% to 50% of individuals screened, and the vast majority of these nodules will be found to be benign [144]. In the NLST, 96.4% of the positive screening results in the LDCT group were false-positive (compared with 94.5% in the radiography group) [48]. The rate of biopsy for nodules later found to be benign has varied, with an average of approximately 30% [144]. False-positive results are associated with psychologic distress for patients and the potential for unnecessary follow-up procedures or treatment. Over the three rounds of screening in the NLST, approximately 72% of individuals with a positive result had diagnostic follow-up of some type, 59% had a clinical procedure, and 4% had a surgical procedure [48]. Major complications in individuals with nodules that proved to be benign were rare (0.1%) [48].

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  25. Before lung cancer screening guidelines were published, which of the following screening tests did physicians order most often?

    LUNG CANCER

    Many healthcare professionals screened for lung cancer before it was recommended, with most using screening tools that have not been associated with decreased mortality. For example, in a survey of 962 physicians (family physicians, general practitioners, and general internists), 55% said they had ordered chest radiography and fewer than 5% had ordered sputum cytology; 22% had ordered LDCT [14]. Several physician-related factors associated with lung cancer screening (before it was recommended) were identified [14,37]:

    • Perception of a screening test's effectiveness

    • Attitude toward recommended screening guidelines

    • Practice experience

    • Perception of a patient's risk for lung cancer

    • Reimbursement and payment for screening

    • Concern about litigation

    • Patient request for screening

    Since the publication of guidelines for lung cancer screening, a small study of 15 leading academic medical centers that offer screening showed that 11 (73%) of the centers limit screening to individuals at high risk as defined in the NLST; one center followed expanded selection criteria, and three centers offered lung cancer screening to any individuals who had participated in shared decision making with a physician [158].

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  26. Routine prostate cancer screening is recommended by the

    PROSTATE CANCER

    RECOMMENDATIONS FOR PROSTATE CANCER SCREENING

    Organization (Year) Screening Recommendation Notes
    National Comprehensive Cancer Network (2019)No routine screeningBegin risk-benefit discussion about baseline DRE and PSA screening at 45 years of age. It is reasonable to consider beginning shared decision-making about PSA screening at 40 years of age for African-American men.
    American Cancer Society (2013, reconfirmed 2019)No routine screeningDiscuss the potential benefits, risks, and uncertainties associated with prostate cancer screening with men who have a life expectancy of at least 10 years; prostate cancer screening should not occur without an informed decision-making process.
    U.S. Preventive Services Task Force (2018)No routine screeningDiscuss the potential benefits and harms of screening with men 55 to 69 years of age. Do not screen men who do not express a preference for screening. Do not routinely screen men 70 years of age and older.
    American Urological Association (2013 reconfirmed 2018)No routine screening
    Decisions should be individualized for men younger than 55 years of age who are at high risk.
    Shared decision making should take place for men 55 to 69 years of age, for whom screening is of greatest benefit.
    American College of Physicians (2013)No routine screening with PSA for average-risk men younger than 50 years of age, men older than 69 years of age, or men with a life expectancy of less than 10 to 15 yearsClinicians should inform their patients 50 to 69 years of age about the limited potential benefits and substantial harms of screening.
    American Society of Clinical Oncology (2012)Discourage general screening for men with a life expectancy of ≤10 years, as the harms outweigh the benefits.Discuss the individual appropriateness of screening with men who have a life expectancy >10 years.
    DRE = digital rectal examination, PSA = prostate-specific antigen.
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  27. A man who is 45 years of age and at high risk for prostate cancer opts to have screening, and the initial prostate-specific antigen (PSA) level is 0.7 ng/mL. Which of the following recommendations is guideline consistent?

    PROSTATE CANCER

    The NCCN recommends baseline PSA testing and consideration of DRE for men who are identified as being at high risk, defined as black race or family history of prostate cancer [162]. If the initial discussion of screening (at 45 years of age) results in measurement of PSA and the level is less than 1.0 ng/mL, a repeat PSA should be done every two to four years [162]. If the PSA level is 1–3 ng/mL and DRE is normal (if performed), repeat testing is recommended at one- to two-year intervals. A PSA level higher than 3.0 ng/mL with a very suspicious DRE finding should prompt a discussion of further testing, including percent-free PSA testing, 4Kscore, or prostate health index blood testing; a repeat PSA/DRE in 6 to 12 months; or a biopsy [162].

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  28. The primary benefit of prostate cancer screening is

    PROSTATE CANCER

    The primary benefit of prostate cancer screening is a lower stage and grade of cancer at the time of diagnosis [40,165,166]. However, despite this benefit, an effect of screening on mortality has not been clearly demonstrated. After 13 years of follow-up in the PLCO trial, there was no benefit of annual screening on mortality [167]. A subsequent meta-analysis (five randomized controlled trials) similarly demonstrated no effect of screening on prostate cancer-specific or overall mortality [168]. However, data from the European Randomized Study of Screening for Prostate Cancer demonstrated that screening reduced the risk for prostate cancer death by 7% to 9% per year [169].

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  29. Which of the following statements about oral cancer screening is TRUE?

    OTHER CANCERS

    In 2010, an expert panel from the American Dental Association Council on Scientific Affairs developed recommendations for oral cancer screening on the basis of five systematic reviews and four clinical studies [178]. The panel concluded that community-based screening by visual and tactile examination may not alter disease-specific mortality among the general population but may decrease disease-specific mortality among people who use tobacco, alcohol, or both [178]. In addition, screening may result in detection of oral cancers at early stages of development (stages I and II). The panel found insufficient evidence to determine whether screening alters disease-specific mortality among asymptomatic people seeking dental care. There was also insufficient evidence that devices based on autofluorescence or tissue reflectance enhanced the detection of potentially malignant lesions beyond that detected by a conventional visual and tactile examination. The panel suggested that "clinicians remain alert for signs of potentially malignant lesions or early-stage cancers in all patients while performing routine visual and tactile examinations," especially for patients who use tobacco or who are considered to be heavy users of alcohol (defined as an average of more than two drinks per day for men and more than one drink per day for women) [178].

    Similarly, the authors of a 2013 meta-analysis on the effectiveness of screening programs for oral cancer found that population-based screening reduced the mortality rate of oral cancer only among high-risk individuals but not among individuals at average risk [179]. Visual examination as part of a screening program significantly reduced mortality by 24% among individuals with a history of alcohol or tobacco use, or both, compared with unscreened individuals [179]. However, the authors of the meta-analysis noted that the evidence was limited to one study with a high risk of bias. As with the American Dental Association review, no evidence supported a reduction in mortality with the use of other screening tools, such as toluidine blue, brush biopsy, or fluorescence imaging.

    The ACS recommends that men and women 20 years of age and older should have examination of the oral cavity as part of a cancer-related check-up during periodic health examinations [40]. The USPSTF updated its recommendations on oral cancer screening in 2013. The Task Force concluded that the current evidence is insufficient to evaluate the benefits and harms of oral cancer screening in asymptomatic adults [180]. The Task Force also noted that the recommendations apply only to primary care providers and not to dental care providers or otolaryngologists [180]. The authors of a 2013 meta-analysis concluded that dental care providers should perform routine oral examinations to detect signs of premalignant disorders or oral cancer [181].

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  30. Which of the following ovarian cancer screening recommendations is guideline consistent for an asymptomatic woman 45 years of age at average risk for ovarian cancer?

    OTHER CANCERS

    The combination of CA-125 and transvaginal ultrasound for ovarian cancer screening among women at average risk was evaluated in the PLCO cancer screening trial. The study enrolled more than 78,000 women, 55 to 74 years of age, who were randomly assigned to annual screening for 6 years or usual care and were followed for a maximum of 13 years. The mortality rate was similar for both groups (3.1 ovarian cancer-related deaths per 10,000 patient-years in the group who had screening vs. 2.6 deaths per 10,000 patient-years in the group who had usual care) [185]. As a result of these and similar findings, major medical organizations agree that ovarian cancer screening is not recommended for asymptomatic women at average risk for the disease [40,186,187]. The USPSTF also notes that substantial harms may be involved with ovarian cancer screening, primarily due to surgical interventions for masses that are not cancerous [187].

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