Page 46 Complete Your CE Test Online - Click Here Food and Drug Administration approved an HPV DNA test that can be used alone for the primary screening of cervical cancer risk in women aged 25 years and older [150]. Co-testing with Pap and HPV DNA Screening every five years with the Pap test and the HPV DNA test (co-testing) in women 30 years and older is more sensitive in detecting cervical abnormalities, compared with the Pap alone. This also means more false positive tests, which require extra testing. Screening with the Pap plus HPV DNA test reduces the incidence of cervical cancer. HPV- based screening provides 60-70% greater protection against invasive cervical carcinoma, compared with cytology (Pap) alone [150,250]. Liquid-based cytology testing Newer techniques that employ liquid-based cytology (such as ThinPrep) are intended to improve the sensitivity of screening. As with the Pap, the optimal studies to determine the sensitivity and specificity of liquid- based cytology have not been done. Some studies showed sensitivity was modestly higher for detecting any degree of cervical intraepithelial neoplasia (CIN), with somewhat lower specificity, but these studies had weaknesses that rendered their findings uncertain. One study that was done more carefully showed that conventional Pap testing was slightly more sensitive and specific than liquid-based cytology [77,150]. The evidence is also mixed about whether liquid-based techniques improve rates of test adequacy. One advantage of liquid-based cytology is that HPV testing can be done on the same preparation if needed, but the liquid-based approaches cost more than conventional Pap testing. No study has yet examined whether liquid-based cytology actually reduces the number of women dying of cervical cancer compared with conventional Pap testing [150]. Women at higher-than-average risk of cervical cancer Depending on medical history, some women may need more frequent or additional screening for cervical cancer than the above guidelines. For example, women who [201]: ● ● Are HIV infected (HIV-positive, whether or AIDS has developed). ● ● Have a weakened immune system. ● ● Were exposed in utero to diethylstilbestrol (DES), which was once prescribed to pregnant women. ● ● Had a recent abnormal Pap test or biopsy result. ● ● Have had cervical cancer. Screening a woman without a cervix Based on solid evidence, screening is not helpful in women of average risk who do not have a cervix as a result of a hysterectomy for a benign condition. No study has shown that screening for vaginal cancer reduces mortality from this rare condition. Among women without cervices, fewer than one in every 1000 patients had abnormal Pap test results [150]. If a woman had a hysterectomy because of DES exposure, cancer, or other high-risk condition, this does not apply. Not recommended: Other screening tests The National Cancer Institute lists a number of tests that are unproven or that have evidence against them for cancer screening: ● ● Alpha-fetoprotein blood test (AFP): The AFP test is sometimes used, along with ultrasound of the liver, to try to detect liver cancer early in people at high risk of the liver cancer. The reported sensitivity of AFP for detecting HCC varies widely in both hepatitis B virus (HBV)-positive and HBV-negative populations, which is attributable to overlap between study designs. When AFP is used for screening of high-risk populations, a sensitivity of 39-97%, a specificity of 76-95%, and a positive predictive value (PPV) of 9-32% have been reported. It is important to know that AFP is not specific for HCC. Titers also rise in acute or chronic hepatitis, in pregnancy, and in the presence of germ cell tumors [173,191]. ● ● CA-125 test: This blood test, which is often conducted along with a transvaginal ultrasound, may be used to try to detect ovarian cancer early, especially in women with an increased risk of the disease. Although this test can help in diagnosing ovarian cancer in women who have symptoms and can be used to evaluate the recurrence of cancer in women previously diagnosed with the disease, there is evidence that it is not effective as an ovarian cancer screening test [191]. The NCI reported on a randomized controlled trial in which the ovarian cancer mortality rate was 3.1 deaths per 10,000 women in the screened group and 2.6 deaths per 10,000 person-years in the usual-care group. Of screened women, 9.6% had false-positive results that resulted in 6.2% undergoing surgery [183,191]. ● ● Regular breast self-exams: The NCI reports that routine self-breast examination (SBE) has not been shown in randomized controlled clinical trials to reduce deaths from breast cancer [191]. Based on solid evidence, formal instruction and encouragement to perform SBE leads to more breast biopsies and diagnosis of more benign breast lesions. The biopsy rate was nearly twice as high (1.8%) among the study population compared to the control group (1.0%) [142]. But monthly SBE is different from breast self-awareness, and it is important for any woman (or man) to know that if there is a lump or other unusual change in the breast, it should be checked right away. ● ● Clinical breast exams: The current evidence is insufficient to assess the additional benefits and harms of clinical breast exam (CBE; examination by a health care provider) [191]. The one randomized controlled trial, the Canadian National Breast Screening Study (NBSS), compared high-quality CBE by nurse-examiners with CBE plus screening mammography. It showed equivalent benefit for both modalities, but accuracy of CBE in the community setting might be lower than in the NBSS [46,142]. ● ● PSA test: This blood test, which is often done along with a digital rectal exam, is able to detect prostate cancer at an early stage. However, expert groups no longer recommend routine PSA testing for most men because studies have shown that it has little or no effect on prostate cancer deaths and leads to overdiagnosis and overtreatment (see “Overdiagnosis and Overtreatment”) [191]. ● ● Skin exams: Doctors often recommend that people who are at risk for skin cancer examine their skin regularly or have a health care provider do so. Such exams have not been shown to decrease the risk of dying from skin cancer, and they may lead to overtreatment [191]. However, people should be aware of changes in their skin, such as a new mole or a change to an existing mole, and report these to doctors promptly. ● ● Transvaginal ultrasound: This imaging test, which can create pictures of the ovaries and uterus, is sometimes used in women who are at increased risk of ovarian cancer (because they carry a harmful BRCA1 or BRCA2 mutation) or of endometrial cancer (because they have a condition called Lynch syndrome). But it has not been proven to reduce deaths from either cancer [191]. Other types of cancer screening not recommended for the general population Ovarian cancer screening: At this time, studies are not promising for screening the general population for ovarian cancer. The U.S. Preventive Services Task Force has set up a plan to evaluate the evidence for ovarian cancer screening methods as of March 2016 [291]. The American Cancer Society has no recommendations for ovarian cancer screenings (see information above regarding CA-125 and transvaginal ultrasounds). Prostate cancer screening: The U.S. Preventive Services Task Force recommends against PSA use for prostate cancer screening [293]. It has no current guidelines to screen for prostate cancer. They are revisiting the topic of prostate cancer screening guidelines now (March 2016) [287]. The American Cancer Society recommends that asymptomatic men receive information about the risks, benefits, and uncertainties of prostate cancer screening. This information should be provided to average-risk men with a life expectancy at least ten years who are 50 years and older, or at earlier ages for men at higher risk of prostate cancer. Screening should not take place without informed decision-making [304].