Ch. 2 Screening and Early Detection
When reviewing cancer-related symptoms, which one of the following would be considered suspicious for cancer? A. Fatigue, malaise, recent weight gain or loss B. Increased blood pressure C. Increased urination, thirst and perspiration D. Stiffness of joints
A. Fatigue, malaise, recent weight or weight loss Rationale: These are considered to be constitutional symptoms which can affect many different systems of the body. Other symptoms can also include fever, chronic pain, dyspnea, night sweats, cough, and decreased appetite. These are nonspecific symptoms which can present in many diseases, but can present in some primary lung malignancies. Therefore, when assessing a patient, it is important to do a thorough physical exam, and review of cancer-related symptoms.
A 62-year-old women with a 22-pack-year smoking history asks if she should be screened for lung cancer. According to the National Comprehensive Cancer Network (NCCN), what would you recommend? A. Lung cancer screening is not recommended. B. Low-dose computed tomography (LDCT) is recommended. C. Sputum cytology with or without chest x-ray is recommended. D. Chest radiography is recommended every 5 years.
A. Lung Cancer screening is not recommended Rationale: Individuals who are over the age of 50 with greater than 20-pack year history of smoking are considered to be at a moderate risk. Lung cancer screening is not recommended for the general population. Screening is to be considered for those between 55 and 80 years of age with at least a 30-pack-year smoking history and those who continue to smoke or have quit less than 15 years ago. In the individuals LDCT, is recommended as it is the most sensitive test available, resulting in a 20% reduction in lung cancer mortality versus a plain chest X-ray.
A 27-year-old female comes in for her routine cervical cancer screening. Which screening test is recommended for her age group? A. Pap test every 3 years B. Human papillomavirus (HPV) test with a Pap test every 5 years C. HPV test with Pap test every 3 years D. Screening would not be recommended if she has been vaccinated.
A. Pap test every 3 years Rationale: Between ages 21-29, cytology (Pap test, also known as a Pap smear) is needed every 3 years. It is the principle screening tool for cervical cancer. Yearly screening is no longer recommended because it generally take 10-20 years for cervical cancer to develop. HPV testing in this age group is only needed after an abnormal Pap result and it not recommended as a routine screening test. Those who are between the ages of 30-65, it is preferred to do an HPV with Pap test every 5 years. However, a Pap test alone every 3 years is also acceptable in this age group. In women who are 65 and older, and have undergone regular cervical cancer testing with normal results, screening is not recommended. For women who have had a hysterectomy, cervical cancer screening is also not needed unless the surgery was done to remove cervical cancer or a precancerous lesion.
A patient with cervical cancer asks whether an HPV vaccine would be recommended for her. The nurse responds based on her understanding that HPV vaccine is a method of: A. primary prevention B. secondary prevention C. tertiary prevention D. quaternary prevention
A. Primary prevention Rationale: The goal of primary prevention is to reduce the risk factors of cancer or increase an individual's resistance to them. This is considered to be the most effective management for cancer. Secondary prevention prevents disease progression by the early detection and treatment of cancer. Tertiary prevention is the application of effective therapy to improve the outcomes and disease morbidity and mortality in affected individuals. Quaternary prevention refers to avoiding consequences of unnecessary or excessive interventions.
The percentage of persons who screen positive and actually have the disease is referred to as: A. positive predictive value B. negative predictive value C. Sensitivity D. Specificity
A. positive predictive value Rationale: A positive predictive value (PPV) identifies the percentage of person who screen positive who actually have the disease. Negative predictive value (NPV) is the percentage of persons who screen negative who do not have the disease. The higher the prevalence of a disease, the higher the PPV and lower the NPV. Sensitivity measures a tests ability to recognize persons who have the disease, also referred to a true positives. In other words, it does not miss any people who are ill. Specificity measures a tests ability to recognize persons who do not have the disease, also referred to as true negatives. This means the test is not precise as it only captures persons who already have the disease.
A 44-year-old patient with colorectal cancer asks about screening for his son. His nurse advises him that the recommended screening guidelines for prevention includes which of the following? A. 50 years of age, or 10 years before the youngest case in the immediate family. B. 40 years of age, or 10 years before the youngest case in the immediate family C. 60 years of age, or 10 years before the youngest case in the immediate family D. Colonoscopy every 10 years and every 6 years after the age of 55 years
B. 40 years of age, or 10 years before the youngest case in the immediate family Rationale: This screening modification is recommended in individuals with a family history of colorectal cancer or colorectal polyps in a first-degree relative due to the increased risk of adenomas or cancer. From the genetic perspective, first-degree relatives (siblings, parents or offspring) should be considered to be at increased risk. Therefore, it is recommended for those individuals get a colonscopy starting at age 40, or 10 years younger than age at diagnosis of the youngest affected relative, whichever is earlier. Observational studies have shown that average time required for a polyp to develop into an invasive malignancy is 10 years. Colonscopy is to occur every 5 years in those who have a first-degree relative with colorectal cancer or adenomatous polyps. In an individual considered to be an average risk, colonscopy is recommended every 10 years, beginning at age 50.
A 45-year-old healthy African American male with a significant family history of prostate cancer asks whether he should be screened for prostate cancer. Which one of the following is the best response to give? A. Screening is not recommended until age 50 years B. It would be beneficial to begin screening C. Screening should be be done in men with comorbidities D. Screening should only be done in men who are healthy with little to no comorbidities
B. It would be beneficial to begin screening Rationale: According to the American Cancer Society, a screening for prostate cancer includes prostate-specific antigen (PSA) blood test and digital rectal exam (DRE). Discussion about screening should take place at age 50 for men with average risk. In men with a high risk, such as being African American, having a first-degree relative diagnosed with prostate cancer before the age of 65, the discussion for screening should begin at age 45. In men with an even higher risk, such having more than one first-degree relative who had prostate cancer at an early age, the discussion for screening should come at age 40.
BRCA1 and BRCA2 mutations are: A. Responsible for approximately 50% of hereditary breast cancers B. are not common enough to recommend testing for the general population C. responsible for approximately 20-25% of hereditary lung cancers D. indicative of a developing cancer if the mutation is found
B. are not common enough to recommend testing for the general population Rationale: BRCA1 and BRCA2 mutations are rare in the general population, therefore genetic testing for these mutations is not recommended unless there is an individual or family history suggesting a possible presence of the mutation. Individuals who have an increased likelihood of having a BRCA1 or BRCA2 mutation are those who have a family history of breast cancer diagnosed before the age of 50, multiple breast cancers in the family breast and ovarian cancer in either women herself of in the family, cancer in both breasts in the women herself, two or more primary types of BRCA1 or BRCA2 related cancers in a single-family member, and Ashkenazi Jewish ethnicity. BRCA1 and BRCA2 gene mutations are responsible for approximately 20-25% of hereditary breast cancer.
Which one of the following is an important component to discuss when performing an assessment on a patient to determine if cancer screening is recommended? A. current medications B. family history C. sleep pattern and exercise D. allergies
B. family history Rationale: Assessing key characteristics can help identify which screening tests are needed for individuals. This involves reviewing their demographic for age, gender, race, and occupation. It also involves reviewing a personal medical history such as previous state of health, previous cancer and cancer treatment, chronic illnesses, vaccinations, and hospitalizations. Reviewing a family history for medical and cancer history in relatives is also important to identify which cancer-oriented screening exams are needed. Medication history, allergies, sleep habits, and exercise are components of a healthy history but they do not generally guide screening recommendations.
J.L. is a 45-year-old African American female who calls to make a mammography appointment. She is asymptomatic without a personal history of breast cancer or breast implants. She will be scheduled for which one of the following types of mammograms? A. breast tomosynthesis B. screening mammogram C. 2D mammogram D. diagnostic mammogram
B. screening mammogram Rationale: This women is asymptomatic. If a problem is detected on physical examination or on the screening mammogram, a diagnostic mammogram will be ordered. Women who have a known symptom of breast cancer (lump, nipple discharge, nipple deviation, skin changes, bulge, or puckering), women with a personal history of breast cancer, or women with breast implants will need a diagnostic mammogram. Screening mammography is recommended for women age 40 and over. Breast tomosynthesis, which is also referred to as three-dimensional (3-D) mammography, is a form of mammography that uses a low-dose X-ray system and computer reconstructions to create three-dimensional images of the breasts. In two-dimensional (2-D) mammography two X-ray images are taken, one from the top and a second from the side. Both 3-D and 2-D mammography can be used for either screening or diagnostic mammograms.
A 27-year-old women who was treated with chemotherapy and thoracic radiation for childhood Hodgkin disease asks about her breast screening guidelines. Based on her history, the screening guidelines should include: A. clinical breast exam every 12 months B. mammogram every other year C. annual mammogram D. bilateral salpingo-oophorectomy
C. Annual mammogram Rationale: This women is considered to be an increase risk for breast cancer as she has had a history of thoracic radiation therapy between the age of 10 and 30 years for her childhood leukemia. Therefore, the screening guidelines will be different for her in comparison to someone who is at an average risk for breast cancer. For women under 25 years of age, a clinical breast exam is recommended every 12 months beginning 8-10 years after radiation therapy. For women who are 25 years of age and older, a clinical breast exam is recommended every 6-12 months, along with an annual breast MRI, and an annual mammogram to begin 8-10 years after radiation therapy, but not prior to age 25.
The nurse is conducting a cancer risk assessment on a 26-year-old female. The components of the patient's history should include which one of the following? A. Assessment of pain and stiffness in bones and joints B. Assessment of the cranial nerves C. Assessment of daily exercise habits D. Assessment of all skin surfaces
C. Assessment of daily exercise habits Rationale: Components of the history include demographic information such as age, gender, race, ethnicity, and occupation. Other components of the history include past medical history and family history of malignancy. Assessment of social habits that potentially increase risk for cancer should also be considered such as a smoking, alcohol, illicit drug use, sexual habits, dietary habits, and amount of regular exercise. Assessment of pain and stiffness in the bones and joints, cranial nerves, and skin surfaces are all part of the physical examination in cancer assessment.
A 35-year-old women is very worried about her risk for developing breast cancer. Her mother was diagnosed with breast cancer at age 34 and her sister was recently diagnosed with breast cancer at age 39. When she was 30 years old she has a benign fibroadenoma removed from her breast. Her first menstrual period was at age 11 and first birth was at age 28. The nurse uses which model to calculate her estimated risk for developing breast cancer in the next 5 years and over a lifetime: A. PREMM model B. BRCAPRO model C. Gail Model D. Penn II model
C. Gail Model Rationale: The Gail model is a multivariable statistical model that has been developed to help estimate a women's personal breast cancer risk. The Gail model incorporates characteristics and risk factors of the woman including age of menarches, age of first live birth, number of first-degree relatives with breast cancer (mother and sister), number of previous benign breast biopsies, atypical hyperplasia in a previous breast biopsy, and race to assess 5-year and lifetime risks of developing breast cancer. It is appropriate to use in women 35 and older. It does not include maternal second and third -degree relatives (grandmother or aunt) paternal family history of breast cancer, height, weight, or family history of ovarian cancer, so it will underestimate breast caner risk for some women. The PREMM model is a clinical prediction model that estimates the probability of an individual carrying a germline mutation in the MLH1, MSH2, MSH6, PMS2, or EPCAM genes. Mutations in these genes cause Lynch syndrome, an inherited caner predisposition syndrome associated with elevated risks of developing colon, uterine, ovarian and other cancers. The Penn II model can be used to predict the pre-test probability that a person has a BRCA1 or BRCA2 mutation. The Penn II model does not predict breast cancer risk. It focuses only on the change that an individual has inherited a mutation in BRCA1 or BRCA2. BRCAPRO is a statistical model used for assessing the probability that an individual caries a germline mutation in the BRCA1 and BRCA2 genes, based on family history of breast and ovarian cancer, based on his or her family's history of breast and ovarian cancer, including male breast cancer and bilateral breast cancer.
A 55-year-old male has a prostate-specific antigen (PSA) blood test with a value of 2.46ng/ml. What are the National Comprehensive Cancer Network (NCCN) guidelines for this PSA value? A. Repeat digital rectal exam (DRE) B. Repeat PSA testing in 6-12 months. C. Repeat PSA testing at 1-2 year intervals D. Repeat PSA testing at 2-4 year intervals
C. Repeat PSA testing at 1-2 year intervals Rationale: For men ages 45-75, the NCCN recommends repeat testing at 1-2 year intervals for a PSA between 1-3ng/mL. If the PSA is less than 1.0 ng/mL, testing should be repeated at 2-4 year intervals. If the PSA greater than 3 ng/mL or the DRE is suspicious, then the PSA should be repeated, Providers should also consider performing a percent free PSA Prostate Health Index (phi) score. Phi is a mathematical formula formula that provides a probability of prostate cancer (PCa) by combining three tests (prostate-specific antigen, free PSA, and psPSA) into a single score. Phi is intended to fill the diagnostic "gap" between PSA screening and a prostate biopsy. the higher specifically of phi means a greater probability of identifying those patients who actually need a biopsy. A transrectal ultrasound (TRUS) guided biopsy should be considered if needed. Follow-up should be done in 6-12 months with a PSA and DRE.
A new fecal occult blood test screening designed to correctly identify individuals with colon cancer is an example of the test's: a. reliability b. negative predictive value c. sensitivity d. specificity
C. Sensitivity Rationale: Sensitivity of a test measures the test's ability to correctly identify individuals with the disease comparing the results to those obtained from a gold standard. Reliability of a test is the level of agreement between measurements taken a different times. Negative predictive value is the percentage of person who screens negative and who do not have the disease. Specificity of a test measures the test's ability to correctly identify individuals who do not have the disease comparing the results to those obtained from a gold standard. Both sensitivity and specificity can show how accurate the results are, but they do not measure reliability.
Cancer screening tests are: A. always safe and not harmful if only done annually. B. diagnostic tests to find out what is the cause of certain symptoms C. designed to detect early disease or risk factors for a disease in health individuals D. offer a cure which may otherwise not be found if it were not done.
C. designed to detect early disease or risk factors for a disease in health individuals Rationale: Screening tests are used to detect early stages of cancer in people who are otherwise healthy without any symptoms. They also help to detect risk factors that could later develop into a disease. Diagnostic tests are usually done to find out what is causing certain symptoms that have already become noticeable. Many of the screening tests are used to detect abnormalities first, which can then be looked at more closely in other tests. However, not all screening tests are safe as there are some which may expose the body to radiation and others can potentially be invasive. Therefore, is it always important to outweigh the risk and benefits of a screening test.
In women 45 years of age and older with an average risk of breast cancer, which of the following are included in the recommended screening guidelines? A. Clinical breast exam every 6-12 months B. Prophylactic surgery (e.g. bilateral salpingo-oophorectomy) C. Annual breast MRI D. Annual mammography
D. Annual mammography Rationale: Average risk for breast cancer is defined as those with no personal history of breast cancer, a strong family history, or a genetic mutation known to increase the risk. In average-risk women aged 45-54 years of age, an annual clinical breast exam with an annual mammography is recommended. For those who are 55 years of age and older with an average risk, they have the option to switch to mammography every other year or choose to continue yearly mammogram. High-risk women are considered to be those with a greater than 20% lifetime risk, BRCA1 or BRCA2 gene mutation, of a first-degree relative, an annual mammography should start at age 30, along with an MRI screening, clinical breast exams every 6-12 months, and consideration of risk reduction strategies such as bilateral salpingo-oophorectomy, or chemoprevention with tamoxifen, raloxifine, or exemestane.
An ideal screening testing would be which one of the following? A. be administered annually B. be available in the hospital setting C. have a low negative predictive value D. be cost-effective
D. be cost-effective Rationale: An effective, ideal screening test has the ability to discriminate between those who have the cancer being screened for and those who do not have a current diagnosis of cancer. Screening tools must be safe, reliable, valid, and cost-effective. The potential benefit of the test should outweigh the results. The interval for screening depends on the natural history of malignancy. Some cancers develop more quickly than others and some have a slower doubling time and do not require annual screening such as colorectal cancer. The location where the screening occurs depends on what is needed for the test. Taking a screening program into the community may actually make the screening more accessible than in a hospital such as a mobile mammography or a skin screening event. It does not necessarily have to be available in the hospital. Negative predictive value refers the probability that persons with a negative screening test truly do not have the disease. A high, not low negative predictive value would be desirable.
