Updates in Cancer Prevention and Screening for 2025: A Pharmacist Primer

Screening for cancer has advanced over the years and is continually changing. It can be challenging for primary care providers to keep up with current recommendations for different cancer types. It is important for pharmacists, as frontline health care providers, to be familiar with cancer screening recommendations for their patients. Counseling should also include being able to recognize signs and symptoms that are red flags and necessitate a visit with a health care professional. As health care providers, pharmacists should reinforce our knowledge of cancer screening recommendations because this enables us to provide the best possible care.

The lifetime risk for receiving a cancer diagnosis at any site is approximately 39.3% based on data from 2018 to 2021.¹ The top 4 cancers diagnosed include breast cancer (female), prostate cancer, lung and bronchus cancer, and colorectal cancer (CRC). The highest mortality rate is seen in lung and bronchus cancer.¹ The good news is, these most common cancer diagnoses have screening recommendations. Additionally, for patients with increased risk factors, physician referral or cancer care facility referral is recommended.

The United States Preventative Services Task Force (USPSTF) publishes evidence-based recommendations for preventative services including behavioral counseling, preventative medications and screenings, and cancer screening. The recommendations are intended for primary care providers to use for preventative care guidance for their patients.² Additional cancer screening recommendations can be found through organizations that focus solely on cancer treatment including the National Comprehensive Cancer Network (NCCN) and the American Cancer Society (ACS).

In addition to the cancer screening recommendations discussed in this article, there are more general concepts to consider. Counseling on cancer prevention should include discussion of risk factors and modifiable behaviors that may lead to an increased risk of developing cancer. According to ACS, behavioral risk factors that increase the likelihood of a cancer diagnosis include tobacco use, excess body weight, physical inactivity, excess alcohol consumption, poor nutrition, sun exposure, and environmental exposure.³ Below will review signs and symptoms, prevention methods and screening recommendations for 6 cancer types.

Breast Cancer

One of the first ways we can extend our knowledge of screening recommendations to our patients is by counseling them on signs and symptoms for breast cancer. The most common presentation for early breast cancer is a painless lump in the breast tissue. Other concerning symptoms may include nipple discharge or retraction, thickening of the skin on the breast, swelling of the breast, pain, an ulcerated area not healing, skin dimpling or swollen lymph nodes under the arm or near the collar bone.⁴ A person experiencing any of these symptoms should seek attention from a health care provider as soon as possible.

A person of average risk should begin screening with an annual mammogram at the age of 40. Image Credit: © lordn - stock.adobe.com

For breast cancer screening, several organizations have published recommendations. The NCCN has 2 published guidelines including Breast Cancer Screening and Diagnosis and Breast Cancer Risk Reduction. These guidelines assess patients based on their risk for developing breast cancer and divide patients into 2 categories: average risk or increased risk. A person of average risk should begin screening with an annual mammogram with 3D imaging (or tomosynthesis) at the age of 40.⁵ The USPSTF breast cancer screening guidelines differ slightly by recommending women aged 40 to 74 receive screening mammography every other year. The guidelines state that women 75 years or older are to assess the benefits and the risks for continuing screening mammography.⁶

The NCCN identifies several factors contributing to an increased risk of developing breast cancer:

• Older age
• Reproductive history: younger age at first menstrual cycle, none or low number of pregnancies, older age at first live birth, older age for start of menopause
• Lifestyle factors: increased body mass, excessive alcohol consumption, exposure to combined hormone replacement medications⁷
• Radiation exposure to chest or breast tissue between 10 and 30 years old
• Family history with a known genetic predisposition

An additional risk factor can be determined from a mammogram: breast density. As of September 10, 2024, the FDA requires all mammogram reports provided to patients include a statement defining the breast tissue as ‘dense’ or ‘not dense’. If reported as ‘dense’ the report will say, “Dense tissue makes it harder to find breast cancer on a mammogram and also raises the risk of developing breast cancer.” For some people this finding may lead to additional imaging after a discussion with a health care provider. Currently, there are not specific guideline recommendations for breast density.⁵

Regarding genetic predisposition, if there is a family history of a first- or second-degree relative diagnosed prior to 50 years of age or 3 or more relatives with a history of breast cancer, individuals should be referred to a genetic counselor or other health care professional knowledgeable of cancer genetics.⁸

Cervical Cancer

Recognition is a key first step for identifying cervical cancer early. Symptoms of early-stage cervical cancer include bleeding after sex, after menopause, between periods or periods that are heavier or longer than normal. Patients may also present with pelvic pain, pain during sex, or vaginal discharge that contains blood. Advanced cervical cancer symptoms could include difficult bowel movements or urination with bleeding, dull backache, or pain in the abdomen.⁹ Individuals experiencing these symptoms should seek medical advice, especially if they have been occurring over an extended period of time and not resolved.

The most important risk factor for cervical cancer is exposure to the human papillomavirus (HPV), specifically the high-risk types, such as HPV 16 and HPV 18 (70%).¹⁰ The HPV virus is spread through sexual activity, and additional risk factors for acquiring the virus include a weakened immune system, smoking, exposure to secondhand smoke, use of oral contraceptives, and obesity.¹⁰ Risk can be mitigated by avoiding sexual activity and receiving the HPV vaccination.

CDC recommends 2 doses of Gardasil-9 (9vHPV) at 6 to 12 months apart for children between the ages of 11 and 12.¹¹ The series may be started at age 9. Additional dosing recommendations are in Table 1. Gardasil-9 is FDA-approved for persons up to 45 years old, but the CDC does not have recommendations to give past the age of 26.¹²

Cervical cancer screening recommendations are provided by the USPSTF. Current recommendations are broken up by age in Table 2. Cervical cytology, also known as Pap smear, looks for precancerous cells on the cervix while the high-risk Human Papillomavirus (hrHPV) test is more sensitive for HPV known to cause cervical cancer.

ACS updated its guidelines in 2020 and recommends screening with a hrHPV test every 5 years for women with a cervix who are average risk and 25 to 65 years old.¹⁴ ACS has alternative recommendations including a co-testing (cervical cytology and hrHPV) every 5 years or a pap test alone every 3 years, due to the lack of availability of the hrHPV test in some areas of the country.¹⁴

Colon Cancer

The NCCN Colorectal Cancer Screening Guidelines highlight risk factors and preventative behaviors to reduce the chance of developing CRC. Risk-reducing lifestyle and dietary behaviors include regular physical activity, a diet high in fruits and vegetables, and smoking cessation.¹⁵ Conversely, factors including diets high in red and processed meat, heavy alcohol consumption, smoking, obesity, and low vitamin D levels have been shown to increase CRC risk.¹⁵ If the following symptoms are reported, you should make a recommendation to see a health care provider for evaluation: rectal bleeding, anemia, abdominal pain that does not subside, and unexplained weight loss.¹⁵

A person of average risk aged 45 to 75 years should begin recommended CRC screening at 45 years old. Multiple screening options exist. Some methods assess the colon visually, whereas others detect possible cancer though stool sampling methods. Depending on which method is used, repeat testing is recommend with varying time frames (Table 3).

A colonoscopy is the gold standard recommendation for screening. It is the most comprehensive tool as it views the colon directly and can remove suspicious polyps during the exam.Other methods that visually assess the colon include flexible sigmoidoscopy and computed tomography (CT) colonography. While less invasive, a positive CT colonography will need a follow-up colonoscopy to address any suspicious areas. The flexible sigmoidoscopy only views the lower part of the colon. For this reason, it should only be used in certain circumstances, potentially in combination with other screening methods.

Other methods for screening assess a stool sample for the presence of markers indicative of CRC. The fecal immunochemical test (FIT) and guaiac-based fecal occult blood tests look for blood hidden in the stool.¹⁶ Multi-targeted stool DNA based testing (Cologuard; Exact Sciences Corporation) detects cancer from abnormal sections of DNA along with detecting hidden blood.¹⁶ Again, with these methods, if a positive result is obtained, a follow-up colonoscopy is recommended.¹⁴

Lung Cancer

The largest number of estimated cancer-related deaths in 2024 is for lung and bronchus cancers.¹ Cigarette smoking is the most prevalent risk factor for developing lung cancer but other risk factors to consider include environmental exposures, prior radiation to the chest, lung disease other than cancer, and family history.¹⁷

Lung cancer symptoms are commonly mistaken for other respiratory diseases. According to the ACS, the most common symptoms of lung cancer are a persistent cough, coughing up blood tinged sputum or overt blood, chest pain with deep breathing or cough, hoarseness, unexplained weight loss, and repeated respiratory infections.¹⁸ If your patient is experiencing any of these symptoms, further work up may be advised.

NCCN provides guidelines for lung cancer screening utilizing low-dose CT (LDCT). A person is eligible for LDCT screening if they are considered high-risk, such as individuals 50 years or older with a 20 pack-year or greater history of cigarette smoking or 20 or more year history of smoking cigarettes.¹⁹ If there are no findings, the NCCN recommends follow-up with continuing annual screenings until treatment for lung cancer is not an option.¹⁹ The USPSTF has similar recommendations for annual LDCT for adults 50 to 80 years old who have a 20 pack-year history and currently smoke or have quit within the past 15 years.¹⁷

Prostate Cancer

According to ACS, early prostate cancer usually does not cause any symptoms but may include difficulty urinating or blood in the urine.²⁰ Advanced prostate cancer may have additional symptoms that indicate the disease has spread outside the prostate, including pain in the hips, back, or chest due to bone disease, weakness, or numbness in the legs or feet from compression of the spinal cord or unintentional weight loss. A patient experiencing any of these symptoms should seek medical advice as soon as possible.

The decision to screen for prostate cancer should be based on a discussion between the patient and physician as there may be risks associated with early detection. The NCCN Prostate Cancer Early Detection Guidelines do not support a blanket screening recommendation.²¹ A baseline evaluation to determine the level of risk includes evaluating family history, any known genetic mutation history for self or family, history of prostate disease, Black/African American race, or environmental exposures.²¹ The NCCN recommends initiating risk assessment discussions at the age of 45 for average risk patients.²¹ If the decision is made to begin screening, a baseline serum prostate specific antigen (PSA) should be drawn along with consideration of a baseline digital rectal exam.²¹ The USPSTF guidelines are in the process of being updated. The last published version in 2018 recommends beginning the discussion about an individual’s decision to screen at 55 to 69 years old and recommends PSA screening alone.²²

Potential harms from PSA screening include frequent false positives that could lead to additional tests such as a prostate biopsy, over-diagnosing and treating, and treatment complications.²² Elevated PSA may be caused by cancer but could also be caused by other conditions such as an enlarged prostate or an inflamed prostate.²² A medication history is important to obtain as certain medications, such as dutasteride, finasteridem, and over-the-counter saw palmetto, may lower PSA levels.

Skin Cancer

Skin cancer of all types is the most commonly diagnosed cancer in the United States with melanoma of the skin being the 5^th most common type of cancer diagnosed according to Surveillance, Epidemiology, and End Results.^1,23 Risk factors that are modifiable include limiting exposure to UV radiation and prevention of frequent sunburns. Risk factors that are not modifiable include fair skin and light-colored eyes and hair.²³ In 2023, the USPSTF released an updated recommendation statement for skin cancer screening concluding that current evidence is insufficient to recommend routine clinical skin examination for the general asymptomatic population.²³ A visual skin examination along with an awareness of skin changes is a good practice to recommend for skin cancer detection.

When performing a visual self-exam, a person should follow the American Academy of Dermatology Association’s ABCDEs of melanoma²⁴_:

1. A – Asymmetry: One half of the spot is unlike the other half.
2. B – Border: The area has an irregular, scalloped or poorly defined border.
3. C – Color: The area has varying colors.
4. D – Diameter: Areas larger than 6 millimeters.
5. E – Evolving: The area looks different over time. Changing in size, shape, or color.

Possessing knowledge of cancer screening recommendations for these common cancer types along with the ability to counsel patients on how to recognize alarming signs and symptoms is a valuable asset to add to your knowledge base. Recommendations reviewed in this article cover the average person without high risk factors. When patients are determined to have a high risk factor for a certain cancer type, other screening and monitor recommendations may be required.

REFERENCES

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7. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) Breast Cancer Risk Reduction, Version 1.2025. August 28, 2024. https://www.nccn.org/professionals/physician_gls/pdf/breast_risk.pdf

8. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) Genetic/Familial High-Risk Assessment: Breast, Ovarian, Pancreatic, and Prostate, Version 2.2025. Accessed November 13, 2024. https://www.nccn.org/professionals/physician_gls/pdf/genetics_bopp.pdf

9. Cervical Cancer Symptoms. National Cancer Institute. October 13, 2022. Accessed November 13, 2024. www.cancer.gov/types/cervical/symptoms

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17. US Preventive Services Task Force, Krist AH, Davidson KW, et al. Screening for Lung Cancer: US Preventive Services Task Force Recommendation Statement. JAMA. 2021;325(10):962-970. doi:10.1001/jama.2021.1117

18. Signs and Symptoms of Lung Cancer. American Cancer Society. Jan 29, 2024. Accessed November 18, 2024. https://www.cancer.org/cancer/types/lung-cancer/detection-diagnosis-staging/signs-symptoms.html

19. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) Lung Cancer Screening, Version 1.2025. October 14, 2024. Accessed November 18, 2024. https://www.nccn.org/professionals/physician_gls/pdf/lung_screening.pdf

20. Signs and Symptoms of Prostate Cancer. American Cancer Society. November 22, 2023. Accessed November 18, 2024. https://www.cancer.org/cancer/types/prostate-cancer/detection-diagnosis-staging/signs-symptoms.html

21. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) Prostate Cancer Early Detection Version 2.2024. NCCN. March 6, 2024. Accessed November 18, 2024. https://www.nccn.org/professionals/physician_gls/pdf/prostate_detection.pdf

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23. US Preventive Services Task Force, Mangione CM, Barry MJ, et al. Screening for Skin Cancer: US Preventive Services Task Force Recommendation Statement. JAMA. 2023;329(15):1290-1295. doi:10.1001/jama.2023.4342

24. What to look for: ABCDES of Melanoma. American Academy of Dermatology Association. 2024. Accessed November 19, 2024. https://www.aad.org/public/diseases/skin-cancer/find/at-risk/abcdes