Breast


HKACS Recommendations 2016

  • Evidence is still insufficient to recommend for or against teaching or performing routine BSE.
  • Women are encouraged to be familiar with their breasts at different times of the month & at different ages and should report any obvious changes promptly.
  • Evidence is insufficient to recommend for or against routine Clinical Breast Examination (CBE) alone to screen for breast cancer.
  • There is insufficient evidence to recommend routine population-based mammography screening to asymptomatic women in Hong Kong as it is still unclear whether screening would cause more good than harm.
  • Women who wish to consider mammography screening in accordance with internationally accepted protocols (e.g. mammography every 1-2 years starting at age 40 or above) should be fully informed of the potential benefits, risks and limitations of screening in order to make an informed choice.
  • If women wish to receive MMG screening, they should start at age 40 instead of 50 because women aged below 45 years accounted for 18.9% of invasive cancer and 20.2% of cancer in-situ (19.1% of both) in all breast cancer new cases in Hong Kong during the period from 2009 and 2013. (HK Cancer Registry)
  • Women who are at higher than average risk of breast cancer (e.g. positive family history of breast cancer) should seek medical advice about whether they should receive screening, age to start and the frequency of screening because the risk of developing breast cancer may be sufficiently high to justify mammography screening.
  • The precise age at which to discontinue screening mammography is still uncertain. Most countries do not actively invite women older than 69 years to attend screening.


Recommendations of Other Countries
Organisation Recommendations
American Cancer Society (ACS)
  • Women with an average risk of breast cancer should undergo regular screening mammography starting at age 45 years (strong recommendation).
  • Women aged 45 to 54 years should be screened annually (qualified recommendation).
  • Women 55 years and older should transition to biennial screening or have the opportunity to continue screening annually (qualified recommendation).
  • Women should have the opportunity to begin annual screening between the ages of 40 and 44 years (qualified recommendation).
  • Women should continue screening mammography as long as their overall health is good and they have a life expectancy of 10 years or longer (qualified recommendation).
  • Does not recommend clinical breast examination for breast cancer screening among average-risk women at any age (qualified recommendation).
U.S. Preventive Services Task Force (USPSTF)
  • Recommends biennial screening mammography for women 50-74 years.
  • The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms.
  • Current evidence is insufficient to assess the benefits and harms of screening mammography in women 75 years and older.
  • Recommends against teaching breast self-examination (BSE).
  • Current evidence is insufficient to assess the additional benefits and harms of clinical breast examination (CBE) beyond screening mammography in women 40 years or older.
  • Current evidence is insufficient to assess the additional benefits and harms of either digital mammography or magnetic resonance imaging (MRI) instead of film mammography as screening modalities for breast cancer.
American College of Obstetricians and Gynecologists (ACOG)
  • Age 40 years is recommended as the starting point in order to find cancer at an early and more treatable stage.
  • Women aged 29–39 years should have a clinical breast exam every 1–3 years. Women aged 40 years and older should have one every year.
  • Always be aware of own breast
American College of Radiology (ACR)
  • Women aged 40 to 74 should be screened with mammography annually.
  • Women aged 75 or above should stop screening with mammography when life expectancy is less than 5 to 7 years on the basis of age or comorbid conditions.


Cervical


HKACS Recommendations 2016

  • For general female population aged 25-64 who have ever had sex, cervical smear at 3-yearly intervals after two consecutive normal annual smears. (1, 1, 3-yearly cycle)
  • Recommends against screening for cervical cancer in women older than age 65 years who have had adequate prior screening and are not otherwise at high risk for cervical cancer.
  • Co-testing using combination of Pap smear plus HPV testing is an appropriate screening test for women older than 30 years. It can lengthen the screening interval from 3 years (Pap smear alone) to 5 years.
  • HPV test is not recommended for screening women younger than age 30


Recommendations of Other Countries
Organisation Recommendations
American Cancer Society (ACS)
  • Women aged 21 to 29, should have a Pap test every 3 years. HPV testing should not be used for screening in this age group (it may be used as a part of follow-up for an abnormal Pap test).
  • Beginning at age 30, the preferred way to screen is with a Pap test combined with an HPV test every 5 years. This is called co-testing and should continue until age 65.
  • Another reasonable option for women 30 to 65 is to get tested every 3 years with just the Pap test.
  • Women over 65 years of age who have had regular screening in the previous 10 years should stop cervical cancer screening as long as they haven't had any serious pre-cancers found in the last 20 years. Women with a history of CIN2 or CIN3 should continue to have testing for at least 20 years after the abnormality was found.
  • Women of any age should NOT be screened every year by any screening method
  • Women who have been vaccinated against HPV should still follow these guidelines.
U.S. Preventive Services Task Force (USPSTF)
  • Recommends screening for cervical cancer in women age 21 to 65 years with cytology (Pap smear) every 3 years or, for women age 30 to 65 years who want to lengthen the screening interval, screening with a combination of cytology and human papillomavirus (HPV) testing every 5 years.
  • Recommends against screening for cervical cancer with HPV testing alone or in combination with cytology, in women younger than age 30 years.
  • Recommends against screening for cervical cancer in women younger than age 21 years.
  • Recommends against screening for cervical cancer in women older than age 65 years who have had adequate prior screening and are not otherwise at high risk for cervical cancer.
American College of Physicians (ACP)
  • Physicians should start screening average risk women for cervical cancer at age 21 once every three years with cytology tests alone. Physicians may use a combination of cytology and HPV (human papillomavirus) testing once every five years in average risk women age 30 and older who prefer screening less often than every three years. Physicians should stop screening average risk women older than 65 years for cervical cancer who have had three consecutive negative cytology results or two consecutive negative cytology plus HPV test results within 10 years with the most recent test performed within five years.
  • Physicians should not screen average risk women younger than 21 years for cervical cancer or screen average risk women for cervical cancer with cytology more often than once every three years. Physicians should not perform HPV testing in average risk women younger than 30 years or screen average risk women of any age for cervical cancer who had a hysterectomy with removal of cervix.
The American Congress of Obstetricians and Gynecologists(ACOG)
  • Women aged 21–29 years should have a Pap test alone every 3 years. HPV testing is not recommended.
  • Women aged 30–65 years should have a Pap test and an HPV test (co-testing) every 5 years (preferred). It also is acceptable to have a Pap test alone every 3 years.
  • Stop having cervical cancer screening after age 65 years if one does not have a history of moderate or severe abnormal cervical cells or cervical cancer, and have had either three negative Pap test results in a row or two negative co-test results in a row within the past 10 years, with the most recent test performed within the past 5 years.




Colorectal


HKACS Recommendations 2016

Individuals aged 50-75 with average risk for colorectal cancer:
  • Annual Faecal Occult Blood Test (FOBT)/Fecal Immunochemical Test (FIT)
  • Flexible sigmoidoscopy (FS) every 5 years
  • Colonoscopy every 10 years


Recommendations of Other Countries
Organisation Recommendations
American Cancer Society (ACS)
  • Starting at age 50, everyone should use one of the screening tests below:
    • Flexible sigmoidoscopy every 5 years
    • Colonoscopy every 10 years
    • Double-contrast barium enema every 5 years
    • CT colonography (virtual colonoscopy) every 5 years
  • Digital rectal examination (DRE) is not recommended as a stand-alone test for colorectal cancer.
*The above recommendations are not applicable to people having history of colorectal cancer or adenomatous polyps, inflammatory bowel disease, strong family history of colorectal cancer or polyps, and known family history of hereditary colorectal cancer syndromes.
U.S. Preventive Services Task Force (USPSTF)
  • Population screening programs between the ages of 50 and 75 years using any of the following 3 regimens will be approximately equally effective in life-years gained:
    1. annual high-sensitivity faecal occult blood testing;
    2. sigmoidoscopy every 5 years combined with high-sensitivity faecal occult blood testing every 3 years, and
    3. screening colonoscopy at intervals of 10 years.
  • The decision to screen in persons aged 76 to 85 years should be an individual one, based on overall health and screening history.
  • Not recommend screening for colorectal cancer in adults older than age 85 years.
  • Evidence is insufficient to assess the benefits and harms of CT colonography and faecal DNA testing as screening modalities for colorectal cancer.
American College of Physicians (ACP)
  • Begin at age 50 for average-risk adults and in high-risk adults at age 40 or 10 years younger than the age at which the youngest relative was diagnosed with colorectal cancer.
  • Screening should cease at age 75 or in individuals with a life expectancy of less than 10 years.
  • A stool-based test, flexible sigmoidoscopy, or optical colonoscopy are acceptable screening tests in patients who are at average risk.
American College of Gastroenterology (ACG)
  • Recommends colonoscopy every 10 years, beginning at age 50 years. For patients who decline colonoscopy or another cancer prevention test, the preferred cancer detection test is FIT, conducted annually.
  • Alternative cancer detection tests recommend are as follows (choose either one) :
    • Flexible sigmoidoscopy every 5-10 years
    • CT colonography every 5 years, which replaces double contrast barium enema as the radiographic screening alternative for patients who decline colonoscopy
    • Annual Hemoccult Sensa
    • Faecal DNA testing every 3 years
For patients with a single first-degree relative diagnosed with colorectal cancer or advanced adenoma before age 60 years, or those with two first-degree relatives with colorectal cancer or advanced adenomas, the guideline recommends colonoscopy every 5 years, beginning at age 40 years or at 10 years younger than the age at diagnosis of the youngest affected relative.


Lung


HKACS Recommendations 2016

  • Screening with chest x-ray plus sputum cytology appears to detect lung cancer at an earlier stage, there is no good evidence that screening for lung cancer using chest x-ray or sputum cytology can reduce lung cancer mortality in many of the previous randomized controlled studies.
  • For adults aged 55-80, with a history of smoking - annual screening for lung cancer with low-dose computed tomography (LDCT) is recommended in adults aged 55 to 80 years who have a 30 pack-year smoking history and currently smoke or have quit within the past 15 years, as there is strong evidence to show that LDCT screening can reduce lung cancer and all-cause mortality.. Screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery.


Recommendations of Other Countries
Organisation Recommendations
American Cancer Society (ACS)
  • Eligibility Criteria for the National Lung Screening Trial with LDCT Screening:
    • Ages 55-74 y, with no signs or symptoms of lung cancer.
    • Active or former smoker with a 30–pack-y history (a pack-y is the equivalent of 1 pack of cigarettes per day per year. One pack per day for 30 years or 2 packs per day for 15 years would both be 30 pack-y). If active smoker, should be vigorously urged to enter a smoking cessation program. Former smoker must have quit within the past 15 years.
  • Screening should not be viewed as an alternative to smoking cessation.
  • Eligible patients should make the screening decision together with their health care provider. Helping individuals to clarify their personal values can facilitate effective decision-making.
  • If lung cancer screening is requested, these patients should be informed that at this time, there is too much uncertainty regarding the balance of benefits and harms for individuals at younger or older ages and/or with less lifetime exposure to tobacco smoke and/or with sufficiently severe lung damage to require oxygen (or other health-related NLST exclusion criteria), and therefore screening is not recommended.
  • Adults who choose to be screened should follow the NLST protocol of annual LDCT screening until they reach age 74 years.
  • CXR should not be used for cancer screening.
U.S. Preventive Services Task Force (USPSTF)
  • Annual screening for lung cancer with low-dose computed tomography (LDCT) in adults aged 55 to 80 years who have a 30 pack-year smoking history and currently smoke or have quit within the past 15 years. Screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery.
Canadian Task Force on Preventive Health Care (CTFPHC)
  • For adults aged 55-74 years with at least a 30 pack-year smoking history who currently smoke or quit less than 15 years ago, we recommend annual screening with LDCT up to three consecutive times. Screening should ONLY be carried out in health care settings with expertise in early diagnosis and treatment of lung cancer.
    (Weak recommendation; low quality evidence)
  • For all other adults, regardless of age, smoking history or other risk factors, we do not recommend screening for lung cancer with LDCT. (Strong recommendation; very low quality evidence)
  • Chest x-ray not to be used to screen for lung cancer, with or without sputum cytology.
    (Strong recommendation; low quality evidence)
American Association for Thoracic Surgery (AATS)
  • Screen adults aged 55 to 79 years with a 30pack-year or more smoking history; adults with a previous diagnosis of lung cancer who have completed 4 years of surveillance without recurrence, and who can tolerate lung cancer treatment following screening to detect second primary lung cancer until the age of 79 years; and adults aged 50 to 79 years with a 20 pack-year smoking history and an additional comorbidity that produces a cumulative risk of lung cancer of 5% or more in 5 years for lung cancer with low-dose CT annually


Prostate


HKACS Recommendations 2016

  • We advise against prostate cancer screening in men age 75 years or older.
  • For men younger than age 75 years, we recommend clinicians to discuss with patients the potential benefits & harms of routine PSA screening for asymptomatic men so as to allow men to make informed choice about PSA testing.
  • Insufficient evidence to recommend for or against screening by DRE in asymptomatic men
  • Transrectal Ultrasound (TRUS) of prostate is generally used as a diagnostic tool for work-up of an abnormal screening test rather than a screening procedure


Recommendations of Other Countries
Organisation Recommendations
American Cancer Society (ACS)
  • Men have a chance to make an informed decision with their health care provider about whether to be screened for prostate cancer. The discussion about screening should take place at:
    • Age 50 for men who are at average risk of prostate cancer and are expected to live at least 10 more years.
    • Age 45 for men at high risk of developing prostate cancer. This includes African Americans and men who have a first-degree relative (father, brother, or son) diagnosed with prostate cancer at an early age (younger than age 65).
    • Age 40 for men at even higher risk (those with more than one first-degree relative who had prostate cancer at an early age).
After this discussion, men who want to be screened should be tested with the prostate-specific antigen (PSA) blood test. The digital rectal exam (DRE) may also be done as a part of screening. The time between future screenings depends on the results of the PSA blood test:
  • Men who choose to be tested who have a PSA of less than 2.5 ng/mL may only need to be retested every 2 years.
  • Screening should be done yearly for men whose PSA level is 2.5 ng/mL or higher.
Because prostate cancer often grows slowly, men without symptoms of prostate cancer who do not have a 10-year life expectancy should not be offered testing since they are not likely to benefit. Overall health status, and not age alone, is important when making decisions about screening.
Even after a decision about testing has been made, the discussion about the pros and cons of testing should be repeated as new information about the benefits and risks of testing becomes available. Further discussions are also needed to take into account changes in a man’s health, values, and preferences.
U.S. Preventive Services Task Force (USPSTF)
  • For men without symptoms, they should not use prostate-specific antigen (PSA)-based screening for prostate cancer.
American Urological Association (AUA)
  • Men should talk to their healthcare provider about whether to get screened or not. They should consider the factors that increase risk for prostate cancer, including:
    • Family history of prostate cancer
    • Ethnicity
    • BMI
    • Age
    • Previous health history
American College of Physicians (ACP)
  • Recommends clinicians to inform men between the age of 50 and 69 years about the limited potential benefits and substantial harms of screening for prostate cancer. A discussion of the benefits and harms of screening, the patient's general health and life expectancy, and patient preferences should be carried out. It is recommended that clinicians should not screen for prostate cancer using the PSA test in patients who do not express a clear preference for screening.
  • Clinicians should not screen for prostate cancer using the prostate-specific antigen test in average-risk men under the age of 50 years, men over the age of 69 years, or men with a life expectancy of less than 10 to 15 years.


Ovarian


HKACS Recommendations 2016

  • Population-based routine screening for asymptomatic women is not recommended at present. However, women with positive family history of ovarian cancer should receive annual screening using serum CA 125 measurement and transvaginal ultrasound as they are at increased risk of developing ovarian cancer.


Recommendations of Other Countries
Organisation Recommendations
The US Food and Drug Administration (FDA)
  • Do not recommend or use tests that claim to screen for ovarian cancer in the general population of women.
  • Testing higher risk asymptomatic patients for ovarian cancer has no proven benefit and is not a substitute for preventive actions that may reduce their risk.
  • Consider referring women at high risk of developing ovarian cancer, including those with BRCA mutations, to a genetic counsellor or gynaecologic oncologist, or other appropriate health care provider for more specialised care.