Cancer screening plays a crucial role in early detection and prevention of various types of cancer. Different screening tests are recommended based on factors such as age, sex, family history, and individual risk factors. This is an overview of current recommendations for cancer screening.

Current Recommendations are outlined below. These recommendations are applicable to individuals who are considered average risk and are based on guidelines from different healthcare organizations. Patients who are at high risk for a given cancer may require a different approach to testing.  Always consult a healthcare professional for personalized advice.

Mammograms

• Women aged 40-49: The American Cancer Society recommends annual mammograms for women aged 40-44, and women aged 45-49 can choose to continue annual mammograms or switch to biennial screenings depending on their preferences and risk factors.
• Women aged 50 and older: Biennial mammograms are recommended for women aged 50-74. After 75, decisions about screening should be based on individual health and life expectancy.

What it entails: Mammography is an X-ray imaging technique used to detect breast cancer in its early stages. During the procedure, the breast is compressed between two plates while X-ray images are taken..
 
Other tests

• Breast sonograms:  Despite its common use, breast mammograms are not recommended for most women as a routine screening test because studies to date have no validated their ability to improve outcomes. Their one valid use is in helping doctors determine if as breast lump if solid or cystic which can guide recommendations for biopsy when a patient or their doctor feels a lump.
• MRI - This test is approved for use in women who have had a previous case of breast cancer or in some patients with very strong family history of breast cancer. It is not approved for average risk individuals
• Thermography - This test has ben marketed as a "radiation free" method to screen for breast cancer. A thermography machine uses an infrared camera to detect temperature differences within your breast tissue. This test has not been shown to be effective at detecting breast cancer in its early stages and is not recommended

• Women aged 21-29: Pap smear (Pap test) is recommended every three years for cervical cancer screening.
• Women aged 30-65: Pap smear combined with HPV (Human Papillomavirus) testing is recommended every five years. Alternatively, a Pap test alone every three years is also an option.

What it entails: A Pap smear involves collecting cells from the cervix to detect any abnormal changes. HPV testing involves checking for the presence of high-risk HPV strains that can lead to cervical cancer.

For women who are hoping to be proactive the HPV vaccine (Gardasil 9) is approved for women up to age 45 and can provide significant protection against the HPV variants that are most likely to cause cancer and genital warts. More than 80% of sexually active women will become HPV positive in their lifetime and HPV vaccination is a safe and effective way to prevent HPV infection and the cancers it can sometimes cause.

Colon cancer is the third leading cause of cancer deaths in men and womenFor average risk individuals aged 45-75: The U.S. Preventive Services Task Force recommends several screening options including

• Colonoscopy -  Colonoscopy involves examining the colon and rectum with a camera attached to a flexible tube inserted through the anus. This test has the ability to detect both cancerous lesions and precancerous polyps. If polyps are found they can be removed through the scope for examination in the lab. For average risk patient this test should be done every 5-10 years.
  • Pros: Can detect and remove cancers and precancerous polyps
  • Cons: Requires a day of fasting and the use of a cleanse the night before the procedure which some patients find objectionable. Also requires the use of anesthesia
• High-sensitivity fecal occult blood testing (FOBT) or Fecal immunochemical testing (FIT) annually.  FOBT/FIT tests detect blood in the stool, which can be a sign of colorectal cancer. If this option is chosen it needs to be done once a year
  • Pros: Easy to do and requires no pretesting preparation
  • Cons: High rate of false positives and false negatives
• DNA Stool test - Cologuard is one commercially available DNA stool test. It is a screening test for colon and rectal cancer. The colon sheds cells from its lining every day. These cells pass with the stool through the colon. Colon cancer cells may have DNA changes in certain genes. Cologuard detects the altered DNA. It is done once every three years.
  • Pros: Easy to do and requires no pretesting preparation
  • Cons: Not very effective at detecting precancerous polyps
• Sigmoidoscopy - This is similar to a colonoscopy in that a scope is inserted into the rectum and into the colon but it only goes about half way through the colon. Because it doesn't go as far up this is often done without anesthesia. If this option is chosen it should be repeated every 10 years of every 5 years if done with annual fecal blood tests.
  • Pros: Can detect and remove cancers and precancerous polyps. Since no anesthesia is required, a patient can drive themselves to and from the procedure without an escort. Can be done by non-specialists
  • Cons: Requires a day of fasting and the use of a cleanse the night before the procedure which some patients find objectionable. Also requires the use of anesthesia. The absence of anesthesia can make this procedure less comfortable than a colonoscopy. Because only half the colon is examined some polyps and tumors may be missed
• CT colonoscopy/ Virtual Colonoscopy - This test uses a CT scan machine to look for polyps. If this option is chosen it should be repeated every 5 years.
  • Pros: No anesthesia is required. Non-invasive
  • Cons: Patients still have to do the same prep as with a colonoscopy and if any polyps or tumors are seen then they will have to schedule a regular colonoscopy for another day and do the same prep all over again.

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Although there are many options for colon cancer screening they are not all equal. Each has its own pros and cons so patients should discuss this with their physician.

• Men aged 55-69: The U.S. Preventive Services Task Force recommends individualized decision-making regarding prostate-specific antigen (PSA) testing. Men should discuss the potential benefits and harms of PSA testing with their healthcare provider.
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What it entails: PSA testing measures the levels of PSA in the blood. Elevated PSA levels can indicate prostate cancer, but can also be normal as men get older and their prostate get larger. Further evaluation, such as a prostate biopsy, is necessary for a definitive diagnosis.

This subject was discussed in detail in a prior blog post
The PSA test - Should you be screened for prostate cancer on your next physical?

Lung cancer is the number one source of cancer deaths in both men and women. It was determined decades ago that chest xrays were not effect screening tools for lung cancer. By the time it showed up on xray it was usually too late. Recent research has shown though that a chest CT might be useful in people who were at high risk. Because a chest CT uses almost 100 times as much radiation as a chest xray and because this would need to be done every year it wouldn't make sense to do a CT on everyone or we might cause more cancers than we cure. For this reason a careful analysis of the data has identified people for whom the benefits outweigh the risks. Because the benefit has been proven both Medicare and private insurance will now pay for this test if the patient meets those criteria.

To be eligible for a screening chest CT a patient must meet the following criteria

• Be between the ages of 50-80 years old
• Have at least a 20 pack year history of smoking (packs per day times number of years of smoking)
• Must be a current smoker or quit no more than 15 years ago

Skin cancer is the most common cancer in men and women and certain types can be deadly.  Current recommendations regarding screening suggest that patients should see a dermatologist once every 2 years for a full body skin check.

Skin cancer can present in various forms, and signs may differ depending on the type of skin cancer. However, some common signs and symptoms include:

• Changes in Skin Appearance: Keep an eye out for any new spots or moles on the skin, or any existing ones that change in size, shape, or color.
• Irregular Borders: Borders of moles or spots that are irregular, scalloped, or poorly defined can be indicative of skin cancer.
• Color Changes: Moles or spots that display multiple colors or shades, such as brown, black, white, blue, or red, may warrant further examination.
• Size Changes: Any growth in size, especially if rapid, of a mole or lesion should be checked by a healthcare professional.
• Evolving Lesions: Lesions that evolve over time, including changes in shape, size, color, or elevation, may indicate skin cancer.
• Itchiness or Pain: Persistent itchiness, tenderness, or pain in a mole or lesion should be evaluated.
• Bleeding or Oozing: Any spot or mole that bleeds, oozes, or crusts over repeatedly should be examined by a healthcare provider.
• Scaly or Rough Texture: Rough, scaly, or crusty patches on the skin that don't resolve with moisturizing or treatment could be a sign of skin cancer.
• Ulceration: Open sores or ulcers that don't heal within a few weeks should be assessed by a dermatologist.
• Changes in Sensation: Any changes in sensation, such as itching, tenderness, or pain, in a mole or spot can be concerning.
• Location: Skin cancer can occur anywhere on the body, but it's more likely to develop in areas exposed to the sun, such as the face, neck, arms, and legs.

Remember that not all changes in the skin are indicative of cancer, but it's important to monitor any changes closely and seek medical advice if you notice anything suspicious. Regular skin self-examinations and yearly visits to a dermatologist can aid in the early detection of skin cancer

It's probably obvious that many cancers are not mentioned among the screening tests listed above. Unfortunately, we don't have proven tests for some of the other common types of cancer. While this is clearly disappointing for both physicians and patients it's important to remember that the only thing worse than no test is a bad test, because if a test does not provide any benefit, then all we get from it is risk. Every test, even a blood test has inherent risk from the test itself as well as the risk posed by additional testing that they trigger. A blood test may seem harmless, but if the result leads to an unnecessary biopsy, then the risk becomes more obvious.

The following tests are not recommended because they either have no evidence to support their use or there is good evidence that they cause more harm than good.

A number of companies are currently marketing whole body MRI's directly to the public.  They claim that these tests can detect cancer and other diseases at an early stage and they imply that this test can save lives. They often showcase futuristic offices and equipment reminiscent of a scene from Star Trek. Some of their promotions feature convincing stories from individuals who claim their lives were saved after tumors and other ailments were detected with this device.

Regardless of the promotional hype, there is no evidence to support the claim that these tests can actually save lives or lead to better outcomes. Moreover, there are reasons for caution.  A significant percentage of healthy individuals who undergo a whole-body MRI will receive abnormal findings necessitating further testing. Some of these additional tests will expose patients to a fair amount of radiation and potentially to invasive procedures, along with associated pain and risks. Anxiety may also accompany patients as they undergo additional testing. While in most cases, these additional tests yield normal results, patients will have experienced all the negative effects and worry without any demonstrable benefit.

Then there is the cost.  These MRI facilities charge between $1500-$2500 for a scan, which is not covered by insurance.

One final note is that a "normal" test does not mean everything is OK. There is the risk that patients who have no abnormal findings on their scan may come away with the false impression that they have gotten a "clean bill of health" and that the proven screening tests we discussed above are not necessary, or that they could at least be postponed for now. That is not true and this misperception could lead to missed opportunities for early cancer detection and ultimately to worse outcomes.

It's worth noting that private insurance and Medicare do not cover these tests, primarily due to the lack of study data supporting their purported life-saving results.  Until they have such data, these tests are not recommended.  I personally discourage my patients from doing them.

Cancer screening when appropriately done, is an essential tool in the fight against cancer, aiding in early detection and improving treatment outcomes. However, it's important to discuss screening options with a healthcare provider to make informed decisions based on individual risk factors and preferences.

Disclaimer: These recommendations may vary based on individual health conditions and guidelines from different healthcare organizations. Always consult a healthcare professional for personalized advice.