Cancer Screening: Let's Talk About It

Over the past 2 decades, the cancer death rate has drastically declined in the United States, falling 23% from its 1991 peak. This translates to 1.7 million lives saved.¹ For women alone, incidence rates also dropped or remained stable between 2003 and 2012, and similar improvements were noted in certain racial and ethnic groups.² Statisticians largely attribute the good news to preventive efforts, early detection, and better treatments. Pharmacists are well positioned to educate patients about all of these. Screening is a particular challenge, however, because of the vast number of screening types and patients’ confusion about which tests are right for them—and when. Counseling sessions offer opportunities to discuss preventive medicine, such as immunizations, healthy lifestyles, and health screenings.

Who Should be Screened?

Cancer does not discriminate, and everyone has some risk. However, certain individuals and age groups are at elevated risk at different times and should be screened. See table 13-11 for a concise overview of the most common recommendations. Multiple organizations (eg, the US Preventive Services Task Force, American Cancer Society, National Comprehensive Cancer Network) have developed cancer screening recommendations. Because clinicians may use different guidelines, pharmacists need a working knowledge of basic recommendations.

Screening Options

Ideally, clinicians would be able to screen for all kinds of cancer, especially those that are the most aggressive and fatal, such as lung cancer and pancreatic cancer. Developing screening tests involves statistical and scientific analysis. Screening can be very costly, invasive, and complicated and may be more harmful than helpful.^12,13 Therefore, expert organizations recommend screening procedures only if they are valid (eg, sensitive and specific) and reliably differentiate between individuals with and without a disease (table 2^14,15). Statisticians and scientists need to weigh these factors when choosing screening tests for the general population.

Screening can be as simple as a breast self-exam or as complex as a colonoscopy. Patients who are at the highest risk may require more than one type of screening test. For example, a woman with a first-degree relative (eg, mother) who had breast cancer has a 20% to 25% lifetime risk of developing this disease and may need early mammograms and annual magnetic resonance imaging. The patient’s decision may be influenced by her health insurance if it does not cover screening tests.¹⁰ Similarly, Medicare covers colonoscopies at no cost, but beneficiaries have a 20% co-pay for a double-contrast barium enema, which can detect smaller tumors and evaluate abdominal symptoms, such as blood in the stool and persistent constipation.^11,16,17

Patients’ perceptions and preference can stand in the way of screening, as patients consider cost, benefits, comfort, and what they may have heard from friends and family. For example, consider patients at elevated risk for colon cancer. These patients often fear colonoscopy because of the bad reputation of bowel preparation. As an alternative, a fecal occult blood test can be done at home. Pharmacists who offer this alternative should counsel patients that the test does not detect polyps and that an additional test may be needed if the lab detects blood in the stool.

Screening reluctance also occurs when patients believe they are perfectly healthy and do not need testing. Using several approaches, pharmacists can coach at-risk patients to undergo appropriate screening (online table 3¹⁸).

The Pharmacist’s Role

The number-one reason why patients skip cancer screenings is a health care provider did not recommend it.¹⁸ Pharmacists can step up, recommend appropriate screenings, and address patients’ reservations with rational explanations. Although screenings have risks (eg, complications from procedures, false-positive results), detecting cancer early increases the likelihood of cure. Pharmacists who develop screening algorithms, make recommendations, and persistently and politely remind patients can make a difference.

Ms. Sharabun is a 2017 PharmD candidate, and Ms. Wick is a visiting professor at The University of Connecticut School of Pharmacy.

References:

• Cancer statistics report: death rate down 23% in 21 years. American Cancer Society website. cancer.org/cancer/news/news/cancer-statistics-report-death-rate-down-23-percent-in-21-years. Published January 7, 2016. Accessed August 23, 2016.
• Annual report to the nation: cancer death rates continue to decline. CDC website. cdc.gov/media/releases/2016/p0309-cancer-death-rate.html. Accessed August 24, 2016.
• Oeffinger KC, Fontham ET, Etzioni R, et al; American Cancer Society. Breast cancer screening for women at average risk: 2015 guideline update from the American Cancer Society. JAMA. 2015;314(15):1599-1614. doi: 10.1001/jama.2015.12783.
• US Preventive Services Task Force (USPSTF). Prostate cancer: screening. USPSTF website. www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/prostate-cancer-screening?ds=1&s=cancer screening. Accessed August 17, 2016.
• U.S. Preventive Services Task Force (USPSTF). Cervical cancer: screening. USPSTF website. www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/cervical-cancer-screening?ds=1&s=cervical%20cancer. Accessed August 18, 2016.
• American Congress of Obstetricians and Gynecologists (ACOG). Cervical cancer screening. ACOG website. acog.org/Patients/FAQs/Cervical-Cancer-Screening. Published February 2016. Accessed August 18, 2016.
• American Cancer Society (ACS). Colorectal cancer prevention and early detection. ACS website. cancer.org/cancer/colonandrectumcancer/moreinformation/colonandrectumcancerearlydetection/colorectal-cancer-early-detection-acs-recommendations. Accessed August 18, 2016.
• Wender R, Fontham ET, Barrera Jr E, et al. American Cancer Society lung cancer screening guidelines. CA Cancer J Clin. 2013;63(2):107-117. doi: 10.3322/caac.21172.
• American Cancer Society (ACS). Prostate cancer prevention and early detection. ACS website.cancer.org/cancer/prostatecancer/moreinformation/prostatecancerearlydetection/prostate-cancer-early-detection-acs-recommendations. Accessed August 18, 2016.
• American Cancer Society (ACS). Breast cancer prevention and early detection. ACS website. cancer.org/cancer/breastcancer/moreinformation/breastcancerearlydetection/breast-cancer-early-detection-acs-recs. Accessed August 22, 2016.
• American Cancer Society (ACS). Colorectal cancer prevention and early detection. ACS website. cancer.org/cancer/colonandrectumcancer/moreinformation/colonandrectumcancerearlydetection/colorectal-cancer-early-detection-screening-coverage-laws. Accessed August 22, 2016.
• Kanchanaraksa S; Johns Hopkins Bloomberg School of Public Health (JHSPH). Evaluation of diagnostic and screening tests: validity and reliability. JHSPH website. ocw.jhsph.edu/courses/FundEpi/PDFs/Lecture11.pdf. Accessed August 29, 2016.
• Cancer Research UK (CRUK). Why isn’t screening available for all cancers? CRUK website. cancerresearchuk.org/about-cancer/screening/why-isnt-screening-available-for-all-cancers. Accessed August 24, 2016.
• Lalkhen AG, McCluskey A. Clinical tests: sensitivity and specificity. Cont Educ Anaesth Crit Care Pain. 2008;8:221-223.
• New York State Department of Health (NYSDOH). Disease screening—statistics teaching tools. NYSDOH website. health.ny.gov/diseases/chronic/discreen.htm. Accessed August 29, 2016.
• Nebraska Colon Cancer Screening Program (NCCSP). Double contrast barium enema (DCBE): what you should know. NCCSP website. dhhs.ne.gov/publichealth/Documents/DoubleContrastBariumEnemaFactSheet.pdf. Accessed August 29, 2016.
• Stop Colon Cancer Now (SCCN). Double contrast barium enema. SCCN website. stopcoloncancernow.com/colon-cancer-prevention/screening-methods/double-contrast-barium-enema-dcbe. Accessed on August 29th, 2016.
• National Colorectal Cancer Roundtable. How to increase preventive screening rates in practice: an action plan for implementing a primary care clinicians evidence-based toolbox and guide. American Cancer Society website. cancer.org/acs/groups/content/@editorial/documents/document/acspc-029276.pdf. Revised 2008. Accessed August 25, 2016.