Practice Guidelines

American Cancer Society Issues 2002 Guidelines for the Early Detection of Cancer

Karen L. Hellekson, PH.D.

The American Cancer Society (ACS) has issued its 2002 update of cancer screening. The ACS announced in 2000 that it would provide a yearly report and regular summary of the current ACS guidelines. The document for 2002, which appears in CA: A Cancer Journal for Clinicians, January/February 2002, does not contain any significantly updated guidelines, although several important updates are expected for 2003.

The screening guidelines are organized by site of cancer and include discussions of recent research, recommended tests or procedures, recommended frequency of testing, and updates on the state of research or clinical trials. The accompanying table on page 684 summarizes the ACS recommendations for cancer screening.

Breast Cancer

The current goal of screening for breast cancer is to discover the cancer in asymptomatic women at an early and treatable stage. The ACS recommends that women begin monthly breast self-examination (BSE) at age 20. Between 20 and 39 years of age, women should undergo a clinical breast examination (CBE), performed by a health care professional, once every three years. Beginning at age 40, women should undergo a CBE and mammography every year. These guidelines should be individualized to the patient: women with a family history of breast cancer, for example, are candidates for more aggressive or more frequent screening.

The breast cancer guidelines were last revised in 1997, and an update is expected for 2003. Despite well-publicized research that has demonstrated that BSE and mammograms are not useful in the early detection of cancer, the ACS, citing problems with the research as well as the conflicting findings of other studies, still recommends that routine BSE and mammography be performed.

Cervical Cancer

Women should begin annual screening for cervical cancer via a Papanicolaou (Pap) test after they initiate sexual activity or at 18 years of age, whichever comes first. After three consecutive negative Pap tests, at the discretion of the doctor, screening can be performed less frequently. An update to the cervical cancer screening guidelines is expected in 2003.

Adenomatous Polyps and Colorectal Cancer

Adults at average risk for adenomatous polyps and colorectal cancer should begin screening at age 50. Screening consists of one of the following: annual fecal occult blood test (FOBT); flexible sigmoidoscopy every five years; annual FOBT plus flexible sigmoidoscopy every five years; double contrast barium enema every five years; or colonoscopy every 10 years. The original report provides separate surveillance criteria for patients with increased or higher risk. The ACS stresses that it is important that physicians recommend at least one of these procedures for all eligible patients.

Endometrial Cancer

The ACS does not recommend screening for endometrial cancer in women without risk factors.

Prostate Cancer

The ACS recommends that men 50 years or older undergo the prostate-specific antigen test and a digital rectal examination every year, if they have a life expectancy of at least 10 years. Men at high risk (including men of African descent or those with a first-degree relative diagnosed at a younger age) should begin testing at age 45.

Lung Cancer

The ACS does not recommend testing for early lung cancer in asymptomatic men or women. However, lung cancer screening tests may be performed on an individual basis. At-risk patients include patients with a history of smoking, significant exposure to second-hand smoke, or an occupation that places them at risk. Such testing should be performed in the presence of specialty groups that can provide diagnosis and follow-up.

Recommendations for the Early Detection of Cancer in Average-Risk, Asymptomatic Patients Cancer site Population Test or procedure Frequency Breast Women, >=20 years Breast self-examination Monthly, starting at age 20     Clinical breast examination Every three years, between 20 and 39 years of age; annual, starting at age 40*     Mammography Annual, starting at age 40 Colorectal Men and women, >= 50 years FOBT and flexible sigmoidoscopy† or Annual FOBT and flexible sigmoidoscopy every five years, starting at age 50     Flexible sigmoidoscopy or Every five years, starting at age 50     FOBT or Annual, starting at age 50     Colonoscopy or Colonoscopy every 10 years, starting at age 50     Double contrast barium enema Every five years, starting at age 50 Prostate Men, >= 50 years Digital rectal examination and prostate-specific antigen test Should be offered annually starting at age 50 for men who have a life expectancy of at least 10 years‡ Cervix Women, >= 18 years Pap test and pelvic examination All women who are, or have been, sexually active, or have reached age 18 should have an annual Pap test and pelvic examination. After a woman has had three or more consecutive satisfactory normal annual examinations, the Pap test may be performed less frequently at the discretion of the physician. Cancer-related checkup Men and women, >= 20 years Examinations every three years between 20 and 39 years of age and annually after age 40. The cancer-related check-up should include examination for cancers of the thyroid, testicles, ovaries, lymph nodes, oral cavity, and skin, as well as health counseling about tobacco, sun exposure, diet and nutrition, risk factors, sexual practices, and environmental and occupational exposures. FOBT = fecal occult blood test; Pap = Papanicolaou. *--Beginning at age 40, annual clinical breast examination should be performed before mammography. †--Flexible sigmoidoscopy with FOBT is preferred, compared with FOBT or flexible sigmoidoscopy alone. ‡--Information should be provided to men about the benefits and limitations of testing. Adapted with permission from Smith RA, Cokkinides V, von Eschenback AC, Levin B, Cohen C, Runowicz CD. American Cancer Society guidelines for the early detection of cancer. CA Cancer J Clin 2002;52:10.

Racial and Ethnic Patterns in Cancer Screening

The report also discusses racial and ethnic patterns in cancer screening. The racial/ethnic groups for the United States are white (non-Hispanic), black (non-Hispanic), Hispanic, American Indian or Alaska Native, and Asian/Pacific Islander. Although few data exist about minority group health behaviors and their use of health care services, disparities clearly exist. These disparities are linked to socioeconomic and cultural factors, lifestyle choices, social environment (such as educational opportunities), aspects of the health care environment, and migration trends.

Conclusion

The ACS guidelines conclude with the reminder that the most important factor in determining whether a patient has a screening test or not is if his or her primary care physician recommends it. The primary care physician is crucial to ensuring that as many people as possible receive routine screening. Physicians need to emphasize the importance of cancer screening to their patients; they need to be able to answer their patients' questions; and they need to be able to explain the benefits, drawbacks, and limitations of cancer screening.