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2014 American Cancer Society

Guidelines and Patient Pages as published in CA: A Cancer Journal for Clinicians

The Guidelines and Patient Pages are published in CA: A Cancer Journal for Clinicians. For the full guidelines, visit cacancerjournal.com CA offers a host of content that enables you to stay abreast of the latest oncology information essential for clinicians working on the frontlines of the battle against cancer.

cacancerjournal.com acsjournals.com/ce @CAonline facebook.com/acsjournals

Table of Contents 3 American Cancer Society Guidelines Process and Patient Pages 4 Cancer screening in the United States, 2014: A review of current American Cancer Society 6 7 9 11 12

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guidelines and current issues in cancer screening

American Cancer Society Lung Cancer Screening Guidelines, 2013 Patient Page: Testing for Lung Cancer in People at High Risk Nutrition and Physical Activity Guidelines for Cancer Survivors, 2012 Patient Page: Nutrition and Physical Activity Guidelines for Cancer Survivors American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology Screening Guidelines for the Prevention and . Early Detection of Cervical Cancer, 2012 Patient Page: Testing for Cervical Cancer

American Cancer Society Guidelines on Nutrition and Physical Activity for Cancer Prevention, 2012

Update 2010

17 Patient Page: A Healthy Diet and Physical Activity Help Reduce Your Cancer Risk 18 American Cancer Society Guideline for the Early Detection of Prostate Cancer: 19 Patient Page: Should I Be Tested for Prostate Cancer? 20 Screening and Surveillance for the Early Detection of Colorectal Cancer and Adenomatous Polyps, 2008

21 American Cancer Society Guidelines for Breast Screening with MRI as an Adjunct to Mammography, 2007

22 American Cancer Society Guideline for Human Papillomavirus (HPV) Vaccine Use to

Prevent Cervical Cancer and Its Precursors, 2007

US Multi-Society Task Force on Colorectal Cancer and the American Cancer Society, 2006

Guidelines for Colonoscopy Surveillance after Cancer Resection: A Consensus Update by the American Cancer Society and US Multi-Society Task Force on Colorectal Cancer, 2006

23 Patient Page: Vaccines to Prevent Cervical Cancer 24 Guidelines for Colonoscopy Surveillance after Polypectomy: A Consensus Update by the 25 

26 American Cancer Society Guidelines for Breast Cancer Screening: Update 2003 27 Patient Page: Finding Breast Cancer Early 29 About CA: A Cancer Journal for Clinicians 30 Meet the Editors 2 American Cancer Society Guidelines

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ACS Guidelines Process Guidelines for Cancer Screening Since 1980, the American Cancer Society (ACS) has introduced and periodically updated guidelines or guidance related to screening and/or informed decision-making about tests for early detection of cancers (and, in some cases, precursor lesions) of the breast, cervix, colon and rectum, endometrium, lung, and prostate. These guidelines address the populations for whom testing is recommended or not recommended, the recommended tests and testing intervals, and the benefits and harms associated with testing for early cancer detection. The ACS recently updated its process for creating cancer screening guidelines to assure consistency with the 2012 Institute of Medicine (IOM) standards. Both the IOM’s recommendations and the American Cancer Society’s new process cover 8 principles: • Transparency (explaining how guidelines are created and funded) • Conflicts of interest • Guideline group composition • Systematic review of evidence • Grading strength of recommendations (explaining the level of confidence in each guideline) • Articulation of recommendations (explaining the guidelines clearly) • External review (getting reviews and comments on the proposed guidelines from outside experts and revising as needed) • Updating (revising guidelines when there is new evidence) As of 2012, the Society now uses a 12-person panel of multidisciplinary, non-specialist experts in clinical screening, including a patient advocate, to create new screening guidelines. Additionally, national and international experts and professional organizations will have the opportunity to provide review and comment on Society guidelines before publication.

Guidelines for Nutrition and Physical Activity The American Cancer Society (ACS) publishes Nutrition and Physical Activity guidelines to advise health care professionals, policy makers, and the general public about dietary and other lifestyle practices that reduce cancer risk. To address the concerns of cancer survivors, the ACS also evaluates the evidence on the relationship between nutrition, physical activity, and issues of quality of life, comorbid conditions, cancer recurrence, the development of second primary cancers, and overall survival and provides recommendations related to nutrition and physical activity after the diagnosis of cancer. The guidelines for cancer prevention and cancer survivors serve as a foundation for ACS communication, policy, and community strategies. These guidelines are developed by a national panel of experts in cancer research, prevention, epidemiology, nutrition, public health, and policy. They are based on synthesis of the current scientific evidence from human population studies and laboratory experiments. The ACS also considers recent meta-analyses and comprehensive reviews of diet, obesity, and physical inactivity in relation to cancer, such as those published by the World Cancer Research Fund and American Institute for Cancer Research. Guidelines are based on the totality of evidence from these sources, taking into account both the potential health benefits and possible risks from adopting them. The ACS guidelines are consistent with guidelines from the American Heart Association and the American Diabetes Association for the prevention of coronary heart disease and diabetes, as well as for general health promotion, as defined by the Dietary Guidelines for Americans and the Physical Activity Guidelines for Americans.

Patient Pages Because the American Cancer Society feels strongly about the dissemination of this life-saving material, in addition to publishing guidelines, key pieces of information from these recommendations are taken and condensed into informational handouts geared towards patients. These patient pages are freely available and can be used by medical institutions to provide further information for their patients, or may be accessed directly by patients seeking more material about the prevention, diagnosis, treatment, and survival of a particular cancer type.

For more information about the American Cancer Society, please visit www.cancer.org. Wiley-Blackwell

American Cancer Society Guidelines 3

CA: A Cancer Journal for Clinicians

Cancer screening in the United States, 2014: A review of current American Cancer Society guidelines and current issues in cancer screening ABSTRACT

Each year the American Cancer Society publishes a summary of its guidelines for early cancer detection, a report on data and trends in cancer screening rates, and select issues related to cancer screening. In this issue of the journal, we summarize current American Cancer Society cancer screening guidelines. In addition, the latest data on the use of cancer screening from the National Health Interview Survey is described, as are several issues related to screening coverage under the Patient Protection and Affordable Care Act, including the expansion of the Medicaid program. In this yearly report, we provide a summary of the current American Cancer Society (ACS) cancer screening guidelines, a summary of guidance to health care professionals and the public related to early cancer detection tests that are not yet recommended for mass screening due to uncertainty about the balance of benefits and harms, and the most recent data on adult cancer screening rates and trends. The ACS monitors the medical and scientific literature on an ongoing basis for new evidence that could lead to a change in cancer screening guidelines, or information about screening that should be conveyed to clinicians and

4 American Cancer Society Guidelines

the public. Under the new guidelines development process, the ACS will initiate an update of guidelines at least every 5 years, or sooner if new evidence warrants an update. The annual guideline reviews, as well as the more detailed cancer screening guideline updates, are published as stand-alone articles and are available online at cacancerjournal.com. Table 1 shows the recent history of guidelines updates, as well as those currently in progress. In this update of ACS cancer screening guidelines, we describe the current guidelines; current issues shaping screening for breast, colorectal, and lung cancer; the most recent data on cancer screening from the National Health Interview Survey (NHIS); and preventive health coverage under Medicaid.

Robert A. Smith PhD, Deana Manassaram-Baptiste PhD, Durado Brooks MD, MPH, Vilma Cokkinides PhD, Mary Doroshenk MA, Debbie Saslow PhD, Richard C. Wender MD, Otis W. Brawley MD Editor-in-Chief of CA, (2014), Cancer screening in the United States, 2014: A review of current American Cancer Society guidelines and current issues in cancer screening, 64: 30–51 CA: A Cancer Journal for Clinicians, DOI: 10.3322/caac.21212

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CA: A Cancer Journal for Clinicians

Cancer screening in the United States, 2014: A review of current American Cancer Society guidelines and current issues in cancer screening, con’t. ACS Recommendations for the Early Detection of Cancer in Average-Risk, Asymptomatic Individuals

ACS indicates American Cancer Society; BSE, breast self-examination; CBE, clinical breast examination; Pap, Papanicolaou; HPV, human papillomavirus; FOBT, fecal occult blood test; FIT, fecal immunochemical test; DRE, digital rectal examination; FSIG, flexible sigmoidoscopy; DCBE, double-contrast barium enema; CT, computed tomography; LDCT, low-dose helical CT; PSA, prostate-specific antigen. a Beginning at age 40 y, annual CBE should ideally be performed prior to mammography. b The stool DNA test approved for colorectal cancer screening in 2008 is no longer commercially available. New stool DNA tests are presently undergoing evaluation and may become available at some future time. Wiley-Blackwell

American Cancer Society Guidelines 5

CA: A Cancer Journal for Clinicians

American Cancer Society Lung Cancer Screening Guidelines ABSTRACT

Findings from the National Cancer Institute’s National Lung Screening Trial established that lung cancer mortality in specific high-risk groups can be reduced by annual screening with low-dose computed tomography. These findings indicate that the adoption of lung cancer screening could save many lives. Based on the results of the National Lung Screening Trial, the American Cancer Society is issuing an initial guideline for lung cancer screening. This guideline recommends that clinicians with access to highvolume, high-quality lung cancer screening and treatment centers should initiate a discussion about screening with apparently healthy patients aged 55 years to 74 years who have at least a 30–pack-year smoking history and who currently smoke or have quit within the past 15 years. A process of informed and shared decision-making with a

clinician related to the potential benefits, limitations, and harms associated with screening for lung cancer with lowdose computed tomography should occur before any decision is made to initiate lung cancer screening. Smoking cessation counseling remains a high priority for clinical attention in discussions with current smokers, who should be informed of their continuing risk of lung cancer. Screening should not be viewed as an alternative to smoking cessation. Richard Wender MD, Elizabeth T. H. Fontham MPH, DrPH, Ermilo Barrera Jr MD, Graham A. Colditz MD, DrPH, Timothy R. Church PhD, David S. Ettinger MD, Ruth Etzioni PhD, Christopher R. Flowers MD, G. Scott Gazelle MD, MPH, PhD, Douglas K. Kelsey MD, PhD, Samuel J. LaMonte MD, James S. Michaelson PhD, Kevin C. Oeffinger MD, Ya-Chen Tina Shih PhD, Daniel C. Sullivan MD, William Travis MD, Louise Walter MD, Andrew M. D. Wolf MD, Otis W. Brawley MD, Robert A. Smith PhD, (2013), American Cancer Society lung cancer screening guidelines. CA: A Cancer Journal for Clinicians, 63: 106–117. doi: 10.3322/caac.21172

View more information on the following Patient Page

6 American Cancer Society Guidelines

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PATIENT PAGE Testing for Lung Cancer in People at High Risk Lung Cancer Facts In the United States, lung cancer is the leading cause of death from cancer. It occurs more commonly after age 60 years. Some people are at a higher risk of developing lung cancer because of their smoking history along with their older age. Smokers can reduce their risk of developing and dying from lung cancer by quitting because the risk of lung cancer steadily increases as long as smoking continues.

age and are in fairly good health and have at least a 30–packyear smoking history and either still smoke or quit within the past 15 years, then your doctor or nurse should talk to you about lung cancer screening. Before you have this discussion, your doctor or nurse should know that high-quality facilities are available to do the screening and follow-up and provide treatment if needed. During this discussion, your doctor or nurse should talk to you about the benefits, limitations, and potential harms of screening.

If lung cancer is diagnosed at an earlier stage, while it is small and before it has spread, people have a better chance of living longer.

Benefit. Screening with LDCT has been shown to reduce

Lung Cancer Screening

lung cancers early, and not all patients who have a lung cancer diagnosed by LDCT will avoid death from lung cancer.

Screening is the medical term for testing to find a disease before it causes any symptoms. Regular x-rays have been tried for lung cancer screening but did not help most people to live longer. The National Cancer Institute recently finished an important study on lung cancer screening called the National Lung Screening Trial (NLST). This study showed that screening in ‘‘high-risk’’ people using low-dose computed tomography, or low-dose CT scan (LDCT), saved lives compared with screening with a chest x-ray. On average, for every 5 people at high risk for lung cancer, getting this test every year can prevent one person from dying of lung cancer. People who meet certain conditions for lung cancer screening (Table 1) should talk with their doctor about being tested. These people should decide whether they want to be tested after a thorough discussion and understanding of the benefits, potential harms, and limitations of screening. Lung cancer screening should only be done in a facility that has experience in lung cancer screening and the management of abnormal findings.

Screening Recommendations From the American Cancer Society The American Cancer Society thoroughly reviewed the subject of lung cancer screening and issued the following recommendation.

the risk of dying from lung cancer.

Limitations. LDCT will not find all lung cancers or all

Harms. There is a chance of a false-positive result. This

means that LDCT might show something wrong when there really is nothing wrong. A false-positive test will require more testing, and an invasive procedure (like removing a sample of lung tissue) might need to be done. Fewer than one in 1000 patients with a false-positive test have a major complication when they have had further testing or procedures. Some deaths from complications of follow-up testing have been reported, but this is rare and most often occurs in patients who do have lung cancer. If you are a current smoker, you should receive smoking cessation counseling. You should be told about your continuing risk of lung cancer and referred to a smoking cessation program. Screening is not an alternative to stopping smoking.

Making Your Decision About Lung Cancer Screening If you are eligible for screening (based on your age an smoking history), you should talk through your thoughts and feelings about screening with your doctor or nurse. They may be able to help you decide what is best for you.

Your doctor or nurse should ask you whether you smoke or used to smoke. If you are between 55 years and 74 years of

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American Cancer Society Guidelines 7

Testing for Lung Cancer in People at High Risk, Con’t. TABLE 1. Criteria to Determine if You Are Eligible for Lung Cancer Screening CHARACTERISTIC

CRITERIA

Age

55-74 years, with no signs or symptoms of lung cancer.

Smoking histor

Current or former smoker with 30–pack-year history (The pack-year history is the number of years you smoked multiplied by your usual number of packs of cigarettes per day. For example, someone who smoked about 2 packs per day for 15 years has 30 pack-years of smoking. A person who smoked one pack per day for 30 years also has 30 pack-years of smoking.)

Active smoker

Current smokers should also be strongly urged to enter a smoking cessation program.

Former smoker

Former smokers must have quit within the past 15 years.

General healt

You should not be screened if you have any metallic implants or devices in your chest or back (as these will interfere with the CT scan), if you require oxygen at home, or if you are in poor health.

People who are more likely to decide to be tested with LDCT every year are those who: •  Value the opportunity to reduce their risk of dying from lung cancer.

•  Are willing to accept the risks and costs of having an LDCT and the likelihood of having more tests.

•  Are willing to accept that, although rare, there might be complications and death from the testing. People who are less likely to decide to be tested with LDCT every year are those who:

•  Place greater value on avoiding testing that carries a high risk of false-positive results and a small risk of complications.

•  Understand and accept that they are at a higher risk of death from lung cancer than they are from screening complications. If you do not meet the above criteria for screening (as shown in Table 1), then you should not be screened.

8 American Cancer Society Guidelines

If you choose to be screened, you should go to a facility that has experience in LDCT screening and has a team of health professionals skilled in the diagnosis and treatment of abnormal lung lesions. If an experienced facility is not available, ask your doctor or nurse about a referral to a center that has the experience. If an experienced facility is not available and you cannot travel to one, then you should not be screened. The risks of screening at a facility that does not meet these conditions may be higher for you. At this time, government and private insurance programs are not likely to provide coverage for an LDCT done for lung cancer screening. Your doctor or nurse should help you determine if your insurance will provide coverage and, if not, help you know how much you will have to pay. There is firm evidence that screening people who are considered ‘‘high risk’’ reduces death rates from lung cancer. © 2013 American Cancer Society, doi:10.3322/caac.21177

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CA: A Cancer Journal for Clinicians

Nutrition and Physical Activity Guidelines for Cancer Survivors ABSTRACT

Cancer survivors are often highly motivated to seek information about food choices, physical activity, and dietary supplements to improve their treatment outcomes, quality of life, and overall survival. To address these concerns, the American Cancer Society (ACS) convened a group of experts in nutrition, physical activity, and cancer survivorship to evaluate the scientific evidence and best clinical practices related to optimal nutrition and physical activity after the diagnosis of cancer. This report summarizes their findings and is intended to present health care providers with the best possible information with which to help cancer survivors and their families make informed choices related to nutrition and physical activity.

The report discusses nutrition and physical activity guidelines during the continuum of cancer care, briefly highlighting important issues during cancer treatment and for patients with advanced cancer, but focusing largely on the needs of the population of individuals who are disease free or who have stable disease following their recovery from treatment. It also discusses select nutrition and physical activity issues such as body weight, food choices, food safety, and dietary supplements; issues related to selected cancer sites; and common questions about diet, physical activity, and cancer survivorship. Cheryl L. Rock PhD, RD, Colleen Doyle MS, RD, Wendy Demark-Wahnefried PhD, RD, Jeffrey Meyerhardt MD, MPH, Kerry S. Courneya PhD, Anna L. Schwartz FNP, PhD, FAAN, Elisa V. Bandera MD, PhD, Kathryn K. Hamilton MA, RD, CSO, CDN, Barbara Grant MS, RD, CSO, LD, Marji McCullough ScD, RD, Tim Byers MD, MPH, Ted Gansler MD, MBA, MPH (2012), Nutrition and physical activity guidelines for cancer survivors. CA: A Cancer Journal for Clinicians, 62: 242–274. doi: 10.3322/caac.21142

View more information on the following Patient Page

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American Cancer Society Guidelines 9

PATIENT PAGE Nutrition and Physical Activity Guidelines for Cancer Survivors Cancer survivors often ask questions about food choices, physical activity, and dietary supplements. They want to learn whether nutrition and physical activity can help them to live longer or feel better. These guidelines are meant to answer some of those questions. Developed by an American Cancer Society (ACS) panel of experts, they will give you as a cancer survivor and your family the information you need to make informed decisions about your food and physical activity choices. Nutrition and physical activity needs for cancer survivors may differ for a number of reasons, including where you are in your cancer experience. Three phases are used below as we discuss nutrition and physical activity. They are: active treatment and recovery, disease-free living or living with stable disease, and living with advanced cancer.

Nutrition During Cancer Treatment and Recovery During cancer treatment, surgery, radiation therapy, and chemotherapy can affect your body’s need for nutrients. These treatments can also affect your eating habits and how your body digests, absorbs, and uses food. Your main nutritional goals during this time are: • To make certain your body’s nutrient and calorie needs are met. • To maintain a healthy weight. • To avoid losing muscle mass. • To ensure that any nutrition-related side effects (such as decreased appetite, mouth sores, difficulty swallowing, etc) are being prevented or managed as best they can. • To improve the quality of your life as you go through treatment. To help you meet these goals, your health care team will look at your current nutritional status. If you are likely to have nutrition-related problems during treatment, your team will do one of 2 things: they will have the registered dietitian on the team see you, or they will help you find a qualified nutrition professional for dietary counseling. Getting help from a registered dietitian during cancer treatment can help to reduce treatment-related symptoms, improve your quality of life, and improve your eating.

Vitamin and Mineral Supplements You may be thinking about using dietary supplements such as vitamins and minerals during your cancer treatment or you may already be taking some supplements. You should know that physicians do not agree on their use. Therefore, if 10 American Cancer Society Guidelines

you are taking any supplements, discuss this with your physician. Many dietary supplements contain levels that are higher than the amount found in food, and some may also be higher than what is recommended for good health. Some contain substances that may affect some chemotherapy drugs. Many cancer experts advise their patients not to take supplements during treatment, or they may suggest using a dietary supplement only when it is needed to treat a deficiency or promote another aspect of health. There currently is no evidence to support taking supplements after a cancer diagnosis to reduce the risk of recurrence. If you are thinking about taking a vitamin or mineral supplement after treatment, check first with your health care team. You will want to know about possible risks and benefits. Some supplements can be useful in correcting specific deficiencies, but most studies have found that the risks of high-dose supplements usually outweigh the benefits. Unless your health care team recommends a supplement for a specific reason, do not take any that contain higher amounts than 100% of the daily value. Your first line of defense should be to strive to get the nutrients you need from nutrient-rich foods and beverages.

Exercise During Cancer Treatment Exercise is safe during cancer treatment, and it has many benefits. It improves bone health, muscle strength, erectile dysfunction, and other quality-of-life measures. Before starting your exercise program, talk with your doctor or health care team. Ask them about when you can start to exercise and how you can be physically active during treatment. Your health care team will consider your condition and your personal preferences as they help you work out a plan. If you are receiving chemotherapy and/or radiation therapy and already have an exercise program, you may need to exercise at a lower intensity and/or for a shorter period of time for a while. The goal should be to be active as much as possible. Some doctors may suggest that you wait to see what side effects you have with chemotherapy before starting physical activity. If you did not exercise before your diagnosis, you might start with low-intensity activities such as stretching and brief, slow walks and progress slowly. continued on next page

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Nutrition and Physical Activity Guidelines for Cancer Survivors, Con’t. Older adults and those with bone metastases, osteoporosis, arthritis, or peripheral neuropathies should pay careful attention to their balance and safety to reduce the risk of falls and injuries. Having a caregiver or exercise professional present during exercise sessions can be helpful.

Eat a variety of healthy foods from plant sources.

If you are unable to exercise, you might ask about physical therapy. Physical therapy during bed rest will help to maintain strength and range of motion and can reduce fatigue and depression.

Living With Advanced Cancer

Recovery After Treatment After you have finished your treatment, you may still have symptoms or side effects that affect your nutrition and physical well-being. It will take some time for them to go away. If you lost weight during treatment, nutrition counseling will help you regain a normal, healthy weight. If you are overweight or obese, counseling can help you achieve a healthy weight. You may also need treatment for other symptoms or side effects that have not gone away. After treatment, a program of regular physical activity will help you recover from treatment and will improve your fitness.

Disease-Free Living or Living With Stable Disease During this phase, setting and achieving goals for weight management, a physically active lifestyle, and a healthy diet will benefit your overall health and quality of life. To help you with these goals, the ACS has developed guidelines in 3 areas: weight management, physical activity, and dietary patterns. These guidelines appear below. Following these guidelines may help to reduce the risk of cancer recurrence and of developing another cancer. They are also important for your heart health.

ACS Guidelines on Nutrition and Physical Activity for Cancer Survivors

• Limit the amount of processed meat and red meat you eat. • Eat 2 1/2 cups or more of vegetables and fruits each day. • Choose whole grains rather than refined grain products.

If you are living with advanced cancer, a healthy diet and physical activity are still important for helping you maintain a sense of well-being and an improved quality of life. Many people with advanced cancer need to change their diet to meet their nutritional needs. They may also change it to help with symptoms or side effects such as fatigue, bowel changes, and a decreased sense of taste or appetite. For those with poor appetite, weight loss, or difficulty in gaining weight, some medicines can help to increase appetite. Nutritional supplements such as high-protein/high-calorie beverages and foods can be helpful to those who cannot eat or drink enough to keep up with their body’s needs. Some people think that tube feedings or intravenous feedings will help them. If you are thinking about these, talk with your doctor about whether these types of feedings will help you. Ask about the benefits and the risks or harms of these feedings, keeping in mind your goals for your cancer treatment. If you are living with advanced cancer and wonder about physical activity, please ask your doctor for advice. There is not enough research on the benefits of exercise for survivors with advanced cancer for the ACS to make general recommendations. Talk to your physician about your personal physical abilities to see if exercise is right for you. For more information on the ACS’s Nutrition and Physical Activity Guidelines for cancer prevention or for cancer survivors, please call us at 1-800-227-2345. ©2012 American Cancer Society, Inc. doi:10.3322/caac.21146

Get to and stay at a healthy weight.

• If you are overweight or obese, limit how much you eat of high-calorie foods and beverages and increase physical activity to promote weight loss. Be active. • • •

Avoid inactivity and return to normal daily activities as soon as possible after diagnosis. Aim to exercise at least 150 minutes per week. Include strength training exercises at least 2 days per week.

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CA

A Cancer Journal for Clinicians

American Cancer Society Guidelines 11

CA: A Cancer Journal for Clinicians

American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology Screening Guidelines for the Prevention and Early Detection of Cervical Cancer ABSTRACT

An update to the American Cancer Society (ACS) guideline regarding screening for the early detection of cervical precancerous lesions and cancer is presented. The guidelines are based on a systematic evidence review, contributions from 6 working groups, and a recent symposium cosponsored by the ACS, the American Society for Colposcopy and Cervical Pathology, and the American Society for Clinical Pathology, which was attended by 25 organizations. The new screening recommendations address age-appropriate screening strategies, including the use of cytology and highrisk human papillomavirus (HPV) testing, follow-up (eg, the management of screen positives and screening intervals for screen negatives) of women after screening, the age at which

to exit screening, future considerations regarding HPV testing alone as a primary screening approach, and screening strategies for women vaccinated against HPV16 and HPV18 infections.

Debbie Saslow PhD, Diane Solomon MD, Herschel W. Lawson MD, Maureen Killackey MD, Shalini L. Kulasingam PhD, Joanna Cain MD, Francisco A. R. Garcia MD, MPH, Ann T. Moriarty MD, Alan G. Waxman MD, MPH9, David C. Wilbur MD, Nicolas Wentzensen MD, PhD, MS, Levi S. Downs Jr MD, Mark Spitzer MD, Anna-Barbara Moscicki MD, Eduardo L. Franco DrPH, Mark H. Stoler MD, Mark Schiffman MD, Philip E. Castle PhD, MPH, Evan R. Myers MD, MPH, ACS-ASCCP-ASCP Cervical Cancer Guideline Committee (2012), American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology Screening Guidelines for the Prevention and Early Detection of Cervical Cancer CA: A Cancer Journal for Clinicians, 62: 147–172. doi:10.3322/caac.21135

View more information on the following Patient Page TABLE 1. Summary of Recommendations POPULATION

PAGE NUMBER

RECOMMENDED SCREENING METHODa

Aged < 21 y

153

No screening

Aged 21-29 y

154-155 Cytology alone every 3 y

M A NA GEM ENT OF SCREEN RESULTS

COM M ENTS

HPV testing should not be used for screening or management of ASC-US in this age group HPV-positive ASC-USb or cytology of LSIL or more severe: Refer to ASCCP guidelines 2

HPV testing should not be used for screening in this age group

Cytology negative or HPV-negative ASC-US b: Rescreen with cytology in 3 y Aged 30-65 y

155-162 HPV and cytology ‘‘cotesting’’ every 5 y (preferred)

HPV-positive ASC-US or cytology of LSIL or more severe: Refer to ASCCP guidelines 2

Screening by HPV testing alone is not recommended for most clinical settings

HPV positive, cytology negative: Option 1: 12-mo follow-up with cotesting Option 2: Test for HPV16 or HPV16/18 genotypes • If HPV16 or HPV16/18 positive: refer to colposcopy • If HPV16 or HPV16/18 negative: 12-mo follow-up with cotesting Cotest negative or HPV-negative ASC-US: Rescreen with cotesting in 5 y

Cytology alone every HPV-positive ASC-USb or cytology of LSIL or more severe: 3 y (acceptable) Refer to ASCCP guidelines 2 Cytology negative or HPV-negative ASC-USb: Rescreen with cytology in 3 y Aged > 65 y

162-163 No screening following adequate negative prior screening

After hysterectomy 163-164

Women with a history of CIN2 or a more severe diagnosis should continue routine screening for at least 20 y

No screening

HPV vaccinated 164-165

Applies to women without a cervix and without a history of CIN2 or a more severe diagnosis in the past 20 y or cervical cancer ever Follow age-specific recommendations (same as unvaccinated women)

ASCCP indicates American Society for Colposcopy and Cervical Pathology; ASC-US, atypical squamous cells of undetermined significance; CIN2, cervical intraepithelial neoplasia grade 2; HPV, human papillomavirus; LSIL, low-grade squamous intraepithelial lesion. a

Women should not be screened annually at any age by any method.

b

ASC-US cytology with secondary HPV testing for management decisions.

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PATIENT PAGE Testing for Cervical Cancer New recommendations from the American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology

Cervical Cancer Facts • The cervix is the lower part of the uterus or womb. It is at the top of the vagina. Cancer that starts in the cells of the cervix is called cervical cancer. • Changes in the cells of the cervix can lead to cervical cancer. These cell changes are caused by a virus called the human papilloma virus (HPV). • If cervical cancer occurs, there are tests to find it early when it is small and easier to treat. These tests can also find cell changes before they become cancer. • Most deaths from cervical cancer could be stopped if more women had tests to find cervical cancer early.

HPV and Cervical Cancer Most HPV infections go away by themselves and cause no symptoms or cell changes. Sometimes infections with certain types of HPV that don’t go away can lead to changes in the cells of the cervix. These changes are called precancers or high-grade lesions. They may progress over many years to cervical cancer if not treated. It often takes 10 years or more for a precancer to become cancer. The goal of cervical cancer screening is to find precancers so they can be treated before they progress to cancer.

Understanding Tests for Cervical Screening There are 2 types of tests for cervical cancer screening. Both tests are done on samples of cells that a doctor, nurse, or physician assistant removes from your cervix. They gently scrape or brush the cervix with a special instrument. 1) The Pap test. The test can find early cell changes that are not yet cancer. If cell changes are found, they can be treated. This can prevent them from becoming cervical cancer. This test also can find cervical cancer at a stage that is easy to treat. 2) The HPV test. This test finds certain HPV infections that can lead to cell changes. These cell changes can progress to cervical cancer if not treated. If cell changes are found, they can be removed from the cervix. This can prevent them from becoming cervical cancer. HPV infections are very common. Most HPV infections go away by themselves and cause no symptoms or cell changes. In most cases, they do not go on to cause cancer. These tests are good, but they are not perfect. They can sometimes report that there are precancers present when Wiley-Blackwell

there really are not. These ‘‘false-positive’’ results can lead to treatments that are not needed. Pap tests have been done yearly in the past, but now we know that yearly Pap tests are not needed. In fact, yearly Pap tests can lead to harm from treatment of cell changes that would never go on to cause cancer. The new screening recommendations (shown below) keep the benefit of testing but lower the risks of unneeded treatment (called ‘‘overtreatment’’). Regular cervical cancer screening is not helpful before age 21 years. Women should start screening at age 21 years and be tested every 3 years with a Pap test. At age 30 years, HPV tests are a useful addition to Pap tests. (They are not useful for screening in younger women.) If a woman tests positive for HPV, she will need further testing to find out if she is likely to have a precancer. If she tests negative on both the Pap and HPV tests, her risk of precancer and cancer is so low that she does not need to be tested again for another 5 years.

Screening Recommendations 1) Cervical cancer screening should begin at age 21 years. Women younger than age 21 years should not be tested with either the Pap test or the HPV test. 2) Women between the ages of 21 and 29 years should have a Pap test every 3 years. HPV testing should not be used in this age group unless it is needed after an abnormal Pap test. 3) Women between the ages of 30 and 65 years should have a Pap test plus an HPV test (called ‘‘co-testing’’) every 5 years. This is preferred, but it is also okay to continue to have Pap tests alone every 3 years. 4) Women older than 65 years who have had regular Pap tests that were normal should not be screened for cervical cancer. Once screening is stopped, it should not be started again. Women who have had serious cervical precancer should be tested for at least 20 years after that diagnosis, even if screening continues past age 65 years. 5) A woman who has had a hysterectomy (with removal of the cervix) for reasons not related to cervical cancer and who has not had cervical cancer or serious precancer should not be screened. 6) A woman who has been vaccinated against HPV should still follow the screening recommendations for her age group. continued on next page American Cancer Society Guidelines 13

Testing for Cervical Cancer, Con’t.

Making Your Pap Test More Accurate

Pelvic Exam Versus Pap Test

There are things you can do to make your Pap test as accurate as possible: • Try not to schedule your appointment for a time during your menstrual period.

Many people confuse pelvic exams with Pap tests. The pelvic exam may be a part of a woman’s health care exam, and may be done even if a Pap and HPV test are not done. The pelvic exam alone will not find cervical cancer at an early stage, and cannot find abnormal cells of the cervix. Only Pap tests, or Pap plus HPV tests, can find early cervical cancers or precancers.

• Do not douche for 48 hours (or 2 days) before the test. • Do not have sex for 48 hours (or 2 days) before the test. • Do not use tampons, birth control foams or jellies, or other vaginal creams or vaginal medications for 48 hours (or 2 days) before the test.

©2012 American Cancer Society, Inc. doi:10.3322/caac.21135.

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American Cancer Society Guidelines on Nutrition and Physical Activity for Cancer Prevention ABSTRACT The American Cancer Society (ACS) publishes Nutrition and Physical Activity Guidelines to serve as a foundation for its communication, policy, and community strategies and, ultimately, to affect dietary and physical activity patterns among Americans. These Guidelines, published approximately every 5 years, are developed by a national panel of experts in cancer research, prevention, epidemiology, public health, and policy, and they reflect the most current scientific evidence related to dietary and activity patterns and cancer risk. The ACS Guidelines focus on recommendations for individual choices regarding diet and physical activity patterns, but those choices occur within a community context that either facilitates or creates barriers to healthy behaviors. Therefore, this committee presents recommendations for community action to accompany the 4 recommendations for individual choices to reduce

cancer risk. These recommendations for community action recognize that a supportive social and physical environment is indispensable if individuals at all levels of society are to have genuine opportunities to choose healthy behaviors. The ACS Guidelines are consistent with guidelines from the American Heart Association and the American Diabetes Association for the prevention of coronary heart disease and diabetes, as well as for general health promotion, as defined by the 2010 Dietary Guidelines for Americans and the 2008 Physical Activity Guidelines for Americans. Lawrence H. Kushi ScD, Colleen Doyle MS, RD, Marji McCullough ScD, RD, Cheryl L. Rock PhD, RD, Wendy Demark-Wahnefried PhD, RD, Elisa V. Bandera MD, PhD, Susan Gapstur PhD, MPH, Alpa V. Patel PhD, Kimberly Andrews, Ted Gansler MD, MBA, MPH, The American Cancer Society 2010 Nutrition and Physical Activity Guidelines Advisory Committee (2012), American Cancer Society Guidelines on Nutrition and Physical Activity for Cancer Prevention CA: A Cancer Journal for Clinicians, 62: 30â&#x20AC;&#x201C;67. doi:10.3322/caac.20139

View more information on the following Patient Page

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PATIENT PAGE A Healthy Diet and Physical Activity Help Reduce Your Cancer Risk Eating smarter and being more active will help you feel better and reduce your cancer risk. These guidelines for nutrition and physical activity were developed by the American Cancer Society to help you reduce your risk of cancer.

How Can I Use These Guidelines? You may already be following our advice. If you are not and want to make changes: • Try some of the tips here. • Start slowly if you wish—small steps can add up to big changes.

Get to and Stay at a Healthy Weight Throughout Your Life • A  im to be as lean as possible without being underweight. If you are overweight or obese, losing even a few pounds will improve your health and is a good place to start. The best way to get and stay leaner is to combine a healthy diet with plenty of physical activity. • Being overweight or obese is linked with an increased risk of developing several types of cancer (and other serious health problems). Overweight and obese people can lower their risk for these health problems by losing weight.

The Right Weight Knowing your body mass index (BMI) can tell you if your weight is right for someone of your height. You can find your BMI by using a simple chart such as the one online at http://www.cancer.org (search for ‘‘BMI calculator’’) or by asking your doctor. Watching what and how much you eat and being more active are keys to weight control.

Be Physically Active Physical activity can lower the risk of several types of cancer by helping you get to and stay at a healthy weight and by affecting the levels of some hormones that contribute to cancer formation.

How Much Activity Do I Need? • Adults: Get at least 150 minutes of moderate or 75 minutes of vigorous activity each week. You can also choose a combination of moderate and vigorous activities—1 minute of vigorous activity can take the place of 2 minutes of moderate activity. For example, 150 minutes of moderate activity, 75 minutes of vigorous activity, and a combination of 100 minutes of moderate activity plus 25 minutes of vigorous activity count as the same amount. Spreading this activity throughout the week is better than trying to accomplish it all in 1 or 2 days. 16 American Cancer Society Guidelines

• Children and teens: Get at least 1 hour of moderate or vigorous activity each day, with vigorous activity on at least 3 days each week. • Anything is better than nothing! Doing any intentional physical activity above your usual activities can have many health benefits.

Don’t Be a Couch Potato • Spend less time sitting and watching television, playing video games, and engaging in other forms of screenbased entertainment.

It Adds Up Your daily amount of activity doesn’t need to be done all at one time, but is most valuable if done at least 20 minutes at a time.

Have Fun and Be Fit You can be active by walking briskly, swimming, gardening, doing housework, and even dancing! The more you do, the better. If you have children, be active with them. Table 1 shows some examples of moderate and vigorous activities.

Eat a Variety of Healthy Foods, With an Emphasis on Plant Sources Choose Foods and Beverages in Amounts That Help You Get to and Stay at a Healthy Weight • R  ead those food labels! Be more aware of portion sizes and calories consumed. ‘‘Low fat’’ or ‘‘nonfat’’ does not always mean ‘‘low calorie’’; some of these foods have lots of calories from added sugar • Don’t supersize your plate and yourself! Eat smaller portions of high-calorie foods. Eat vegetables, whole fruit, and other low-calorie foods instead of high-calorie foods such as French fries, potato and other chips, ice cream, doughnuts, and other sweets. • Limit the number of sugar-sweetened beverages you drink such as soft drinks, sports drinks, and fruit drinks. • When you eat away from home, choose foods low in calories, fat, and sugar and avoid eating large portions.

Limit the Amount of Processed Meat and Red Meat You Eat • Lower how much you eat of processed meats such as bacon, sausage, luncheon meats, and hot dogs. • Choose fish, poultry, or beans instead of red meat (beef, pork, and lamb). • If you eat red meat, select lean cuts and eat smaller portions. • Prepare meat, poultry, and fish by baking, broiling, or poaching rather than by frying or charbroiling. continued on next page Wiley-Blackwell

A Healthy Diet and Physical Activity Help Reduce Your Cancer Risk, Con’t. Eat 2 / Cups or More of Vegetables and Fruits Each Day 1

2

• Include vegetables and fruits at every meal and eat them for snacks. • Eat a variety of vegetables and fruits each day. • Choose whole vegetables and fruits and 100% juice if you drink vegetable or fruit juices. • Limit use of creamy sauces, dressings, and dips with vegetables and fruits.

Choose Whole Grains Rather Than Refined Grain Products • Choose whole-grain foods such as whole-grain breads, pasta, and cereals (such as barley and oats) over breads, pasta, and cereals made from refined grains and brown rice over white rice. • Limit how much you eat of refined carbohydrate foods such as pastries, candy, sweetened breakfast cereals, and other high-sugar foods.

If You Drink Alcoholic Beverages, Limit How Much You Drink • Drink no more than 1 drink per day for women or 2 per day for men. • A drink is 12 ounces of regular beer, 5 ounces of wine, or 1.5 ounces of 80-proof distilled spirits. • Alcohol increases your risk of developing several types of cancer (including breast, mouth, throat, larynx, esophagus, liver, colon, and rectum cancers) and several other health problems.

Help to Create Healthy and Active Communities Any change you try to make for a healthier lifestyle is easier when you live, work, play, or go to school in a community that supports healthy behaviors. Look for ways to make your community a healthier place to live. • Ask for healthier meal and snack choices at school or work. Support stores and restaurants that sell or serve healthy options. • Help make your community an easier place to walk, bike, and enjoy a variety of physical activities.

TABLE 1. Examples of Moderate and Vigorous Intensity Physical Activities M ODERA TE I NTENSI TY A CTI VI TI ES

VI GOROUS I NTENSI TY A CTI VI TI ES

Exercise and leisure

Walking, dancing, leisurely bicycling, ice and roller skating, horseback riding, canoeing, yoga

Jogging or running, fast bicycling, circuit weight training, swimming, jumping rope, aerobic dance, martial arts

Sports

Downhill skiing, golfing, volleyball, softball, baseball, badminton, doubles tennis

Cross-country skiing, soccer, field or ice hockey, lacrosse, singles tennis, racquetball, basketball

Home activities

Mowing the lawn, general yard and garden maintenanc

Digging, carrying and hauling, masonry, carpentry

Occupational activity

Walking and lifting as part of the job (custodial work, farming, auto or machine repair)

Heavy manual labor (forestry, construction, fire fighting)

©2012 American Cancer Society, Inc. doi:10.3322/caac.20139.

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American Cancer Society Guideline for the Early Detection of Prostate Cancer: Update 2010 ABSTRACT

In 2009, the American Cancer Society (ACS) Prostate Cancer Advisory Committee began the process of a complete update of recommendations for early prostate cancer detection. A series of systematic evidence reviews was conducted focusing on evidence related to the early detection of prostate cancer, test performance, harms of therapy for localized prostate cancer, and shared and informed decision making in prostate cancer screening. The results of the systematic reviews were evaluated by the ACS Prostate Cancer Advisory Committee, and deliberations about the evidence occurred at committee meetings and during conference calls. On the basis of the evidence and consensus process, the Prostate Advisory Committee developed the guideline, and a writing committee drafted a guideline document that was circulated to the entire committee for review and revision. The document was then circulated to peer reviewers for feedback, and finally to the ACS Mission Outcomes

Committee and the ACS Board of Directors for approval. The ACS recommends that asymptomatic men who have at least a 10-year life expectancy have an opportunity to make an informed decision with their health care provider about screening for prostate cancer after they receive information about the uncertainties, risks, and potential benefits associated with prostate cancer screening. Prostate cancer screening should not occur without an informed decisionmaking process. Men at average risk should receive this information beginning at age 50 years. Men in higher risk groups should receive this information before age 50 years. Men should either receive this information directly from their health care providers or be referred to reliable and culturally appropriate sources. Patient decision aids are helpful in preparing men to make a decision whether to be tested. Andrew M.D. Wolf MD, Richard C. Wender MD, Ruth B. Etzioni PhD, Ian M. Thompson MD, Anthony V. Dâ&#x20AC;&#x2122;Amico MD, PhD, Robert J. Volk PhD, Durado D. Brooks MD, MPH, Chiranjeev Dash MD, Idris Guessous MD, Kimberly Andrews, Carol DeSantis MPH, Robert A. Smith PhD (2010), American Cancer Society Guideline for the Early Detection of Prostate Cancer: Update 2010 CA: A Cancer Journal for Clinicians, 60: 70â&#x20AC;&#x201C;98. doi:10.3322/caac.20062

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PATIENT PAGE Should I Be Tested for Prostate Cancer? If you are concerned about prostate cancer, or if it is time for you to think about testing, talk with your doctor. After this talk, decide if testing is the right choice for you. Prostate cancer affects many men. It is a common cause of death for men. There are tests to find prostate cancer early. Talk to your doctor about the benefits and risks of prostate cancer testing. Then decide if you want to be tested. Have this talk with your doctor starting at age 50. If you are African American or have a family history of prostate cancer, have this talk starting at age 45. If 2 or more men in your family had prostate cancer before they were 65 years old, talk with your doctor about testing when you turn 40. If you are having symptoms—such as blood in your urine, trouble having an erection, difficulty or pain with passing urine, or bone pain—you need to see your doctor now. These could be symptoms of prostate cancer. But they could be caused by other diseases, too. The only way to know for sure is to see your doctor. Here is what experts know about prostate cancer testing and treatment. • Testing will find prostate cancer earlier than if no testing is done • Testing for prostate cancer is performed with the prostate-specific antigen (PSA) blood test with or without a rectal exam. • Testing is not perfect. Some men with increased PSA in their blood may not have prostate cancer. And some men with prostate cancer may have a PSA level that is not increased. • Some men who have cancer may not need to be treated right away. They still will need to be watched closely to see whether the cancer changes or grows. • The treatments for prostate cancer can lead to side effects. These can be problems with passing urine, problems with bowels, and/or problems having sex. For some men, these problems are mild and last for a few weeks or months. In other men, these problems last for the rest of their lives.

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Here is what experts do not know about prostate cancer testing and treatment. • When testing finds prostate cancer, it is often not clear which men will have the type of prostate cancer that will be a serious threat to their health or cause death. • When testing finds prostate cancer, it is often not clear which men will have the type of prostate cancer that is not likely to affect their health. • It is often not known which men will do well with treatment. • It is often not known which men will do well with no treatment. When you think about getting a test for prostate cancer, also think about what you want for yourself. Ask yourself these questions. • Is it important for me to know that I have prostate cancer even if my chances of surviving it are not improved? • Am I willing to be treated even though I may not benefit from treatment? • If I choose to be treated, can I live with the side effects, if they occur? Be sure to discuss these and your own questions with your doctor. Then, you decide whether a test for prostate cancer is the right choice for you. For more information on prostate cancer and prostate cancer testing, please call us anytime day or night at 1-800-227- 2345. To order copies of the American Cancer Society’s informational brochure from which this Patient Page was adapted, call and ask for item number 2650.

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Screening and Surveillance for the Early Detection of Colorectal Cancer and Adenomatous Polyps, 2008 ABSTRACT

In the United States, colorectal cancer (CRC) is the third most common cancer diagnosed among men and women and the second leading cause of death from cancer. CRC largely can be prevented by the detection and removal of adenomatous polyps, and survival is significantly better when CRC is diagnosed while still localized. In 2006 to 2007, the American Cancer Society, the US Multi Society Task Force on Colorectal Cancer, and the American College of Radiology came together to develop consensus guidelines for the detection of adenomatous polyps and CRC in asymptomatic average-risk adults. In this update of each organization’s guidelines, screening tests are grouped into those that primarily detect cancer early and those that can detect cancer early and also can detect adenomatous polyps, thus providing a greater potential for prevention through

polypectomy. When possible, clinicians should make patients aware of the full range of screening options, but at a minimum they should be prepared to offer patients a choice between a screening test that is effective at both early cancer detection and cancer prevention through the detection and removal of polyps and a screening test that primarily is effective at early cancer detection. It is the strong opinion of these 3 organizations that colon cancer prevention should be the primary goal of screening. Dr. Bernard Levin MD, Dr. David A. Lieberman MD, Dr. Beth McFarland MD, Dr. Robert A. Smith PhD, Dr. Durado Brooks MD, MPH, Ms. Kimberly S. Andrews, Dr. Chiranjeev Dash MD, PH, Dr. Francis M. Giardiello MD, Dr. Seth Glick MD, Dr. Theodore R. Levin MD, Dr. Perry Pickhardt MD, Dr. Douglas K. Rex MD, Dr. Alan Thorson MD, Dr. Sidney J. Winawer MD (2008), Screening and Surveillance for the Early Detection of Colorectal Cancer and Adenomatous Polyps, 2008 CA: A Cancer Journal for Clinicians, 58: 130–160.

Guidelines for Screening for the Early Detection of Colorectal Cancer and Adenomas for Average-risk Women and Men Aged 50 Years and Older The following options are acceptable choices for colorectal cancer screening in average-risk adults beginning at age 50 years. Since each of the following tests has inherent characteristics related to prevention potential, accuracy, costs, and potential harms, individuals should have an oppo rtunity to make an informed decision when choosing one of the following options. In the opinion of the guidelines development committee, colon cancer prevention should be the primary goal of colorectal cancer screening. Tests that are designed to detect both early cancer and adenomatous polyps should be encouraged if resources are available and patients are willing to undergo an invasive test. Tests that Detect Adenomatous Polyps and Cancer Test

Interval

Key Issues for Informed Decisions

FSIG with insertion to 40 cm or to splenic flexure

Every 5 years

• • • •

Complete or partial bowel prep is required Sedation usually is not used, so there may be some discomfort during the procedure The protective effect of sigmoidoscopy is primarily limited to the portion of the colon examined Patients should understand that positive findings on sigmoidoscopy usually result in a referral for colonoscopy

Colonoscopy

Every 10 years

• Complete bowel prep is required • Conscious sedation is used in most centers; patients will miss a day of work and will need a chaperone for transportation from the facility • Risks include perforation and bleeding, which are rare but potentially serious; most of the risk is associated with polypectomy

DCBE

Every 5 years

• Complete bowel prep is required • If patients have one or more polyps 6 mm, colonoscopy will be recommended; follow-up colonoscopy will require complete bowel prep • Risks of DCBE are low; rare cases of perforation have been reported

CTC

Every 5 years

• Complete bowel prep is required • If patients have one or more polyps 6 mm, colonoscopy will be recommended; if same day colonoscopy is not available, a second complete bowel prep will be required before colonoscopy • Risks of CTC are low; rare cases of perforation have been reported • Extracolonic abnormalities may be identified on CTC that could require further evaluation

Tests that Primarily Detect Cancer Test

Interval

gFOBT with high sensitivity for cancer

Annual

FIT with high sensitivity for cancer

Annual

sDNA with high sensitivity for cancer

Interval uncertain

Key Issues for Informed Decisions • Depending on manufacturer’s recommendations, 2 to 3 stool samples collected at home are needed to complete testing; a single sample of stool gathered during a digital exam in the clinical setting is not an acceptable stool test and should not be done • Positive tests are associated with an increased risk of colon cancer and advanced neoplasia; colonoscopy should be recommended if the test results are positive • If the test is negative, it should be repeated annually • Patients should understand that one-time testing is likely to be ineffective • An adequate stool sample must be obtained and packaged with appropriate preservative agents for shipping to the laboratory • The unit cost of the currently available test is significantly higher than other forms of stool testing • If the test is positive, colonoscopy will be recommended • If the test is negative, the appropriate interval for a repeat test is uncertain

Abbreviations: FSIG, flexible sigmoidoscopy; DCBE, double-contrast barium enema; CTC, computed tomography colonography; gFOBT, guaiac-based fecal occult blood test; FIT, fecal immunochemical test; sDNA, stool DNA test.

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American Cancer Society Guidelines for Breast Screening with MRI as an Adjunct to Mammography ABSTRACT

New evidence on breast Magnetic Resonance Imaging (MRI) screening has become available since the American Cancer Society (ACS) last issued guidelines for the early detection of breast cancer in 2003. A guideline panel has reviewed this evidence and developed new recommendations for women at different defined levels of risk. Screening MRI is recommended for women with an approximately 20–25% or greater lifetime risk of breast cancer, including women with a strong family history of breast or ovarian cancer and women who were treated for Hodgkin disease. There are several risk subgroups for which the available data are insufficient to recommend for

or against screening, including women with a personal history of breast cancer, carcinoma in situ, atypical hyperplasia, and extremely dense breasts on mammography. Diagnostic uses of MRI were not considered to be within the scope of this review. Dr. Debbie Saslow PhD, Dr. Carla Boetes MD, PhD, Dr. Wylie Burke MD, PhD, Dr. Steven Harms MD, Dr. Martin O. Leach PhD, Dr. Constance D. Lehman MD, PhD, Dr. Elizabeth Morris MD, Dr. Etta Pisano MD, Dr. Mitchell Schnall MD, PhD, Dr. Stephen Sener MD, Dr. Robert A. Smith PhD, Dr. Ellen Warner MD, Dr. Martin Yaffe PhD, Ms. Kimberly S. Andrews, Dr. Christy A. Russell MD, for the American Cancer Society Breast Cancer Advisory Group (2007), American Cancer Society Guidelines for Breast Screening with MRI as an Adjunct to Mammography CA: A Cancer Journal for Clinicians, 57: 75–89.

Recommendations for Breast MRI Screening as an Adjunct to Mammography Recommend Annual MRI Screening (Based on Evidence*) BRCA mutation First-degree relative of BRCA carrier, but untested Lifetime risk ~20–25% or greater, as defined by BRCAPRO or other models that are largely dependent on family history Recommend Annual MRI Screening (Based on Expert Consensus Opinion†) Radiation to chest between age 10 and 30 years Li-Fraumeni syndrome and first-degree relatives Cowden and Bannayan-Riley-Ruvalcaba syndromes and first-degree relatives Insufficient Evidence to Recommend for or Against MRI Screening‡ Lifetime risk 15–20%, as defined by BRCAPRO or other models that are largely dependent on family history Lobular carcinoma in situ (LCIS) or atypical lobular hyperplasia (ALH) Atypical ductal hyperplasia (ADH) Heterogeneously or extremely dense breast on mammography Women with a personal history of breast cancer, including ductal carcinoma in situ (DCIS) Recommend Against MRI Screening (Based on Expert Consensus Opinion ) Women at 15% lifetime risk *Evidence from nonrandomized screening trials and observational studies. †Based on evidence of lifetime risk for breast cancer. ‡Payment should not be a barrier. Screening decisions should be made on a case-by-case basis, as there may be particular factors to support MRI. More data on these groups is expected to be published soon.

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American Cancer Society Guideline for Human Papillomavirus (HPV) Vaccine Use to Prevent Cervical Cancer and Its Precursors ABSTRACT

The American Cancer Society (ACS) has developed guidelines for the use of the prophylactic human papillomavirus (HPV) vaccine for the prevention of cervical intraepithelial neoplasia and cervical cancer. These recommendations are based on a formal review of the available evidence. They address the use of prophylactic HPV vaccines, including who should be vaccinated and at what age, as well as a summary of policy and implementation issues. Implications for screening are also discussed.

Saslow, D., Castle, P. E., Cox, J. T., Davey, D. D., Einstein, M. H., Ferris, D. G., Goldie, S. J., Harper, D. M., Kinney, W., Moscicki, A.-B., Noller, K. L., Wheeler, C. M., Ades, T., Andrews, K. S., Doroshenk, M. K., Kahn, K. G., Schmidt, C., Shafey, O., Smith, R. A., Partridge, E. E. and Garcia, F. (2007), American Cancer Society Guideline for Human Papillomavirus (HPV) Vaccine Use to Prevent Cervical Cancer and Its Precursors. CA: A Cancer Journal for Clinicians, 57: 7–28. doi: 10.3322/ canjclin.57.1.7

View more information on the following Patient Page Summary of American Cancer Society (ACS) Recommendations for Human Papillomavirus (HPV) Vaccine Use to Prevent Cervical Cancer and Its Precursors • Routine HPV vaccination is recommended for females aged 11 to 12 years. • Females as young as age 9 years may receive HPV vaccination. • HPV vaccination is also recommended for females aged 13 to 18 years to catch up missed vaccine or complete the vaccination series. • There are currently insufficient data* to recommend for or against universal vaccination of females aged 19 to 26 years in the general population. A decision about whether a woman aged 19 to 26 years should receive the vaccine should be based on an informed discussion between the woman and her health care provider regarding her risk of previous HPV exposure and potential benefit from vaccination. Ideally the vaccine should be administered prior to potential exposure to genital HPV through sexual intercourse because the potential benefit is likely to diminish with increasing number of lifetime sexual partners. • HPV vaccination is not currently recommended for women over age 26 years or for males. • Screening for cervical intraepithelial neoplasia and cancer should continue in both vaccinated and unvaccinated women according to current ACS early detection guidelines. * Insufficient evidence of benefit in women aged 19 to 26 years refers to (1) clinical trial data in women with an average of 2, and not more than 4, lifetime sexual partners, indicating a limited reduction in the overall incidence of cervical intraepithelial neoplasia (CIN)2/3; (2) the absence of efficacy data for the prevention of HPV16/18-related CIN2/3 in women who have had more than 4 lifetime sexual partners; and (3) the lack of cost-effectiveness analyses for vaccination in this age group.

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PATIENT PAGE Vaccines to Prevent Cervical Cancer Cervical Cancer Facts • The cervix is part of the uterus (or womb). Cancers that start in the cervix are called cervical cancer.

• In 2006, about 9,700 women in the United States will develop invasive cervical cancer, and about 3,700 women will die of the disease. Most of the deaths could be prevented if more women had routine tests to find cervical precancers and early cervical cancer.

Research also has shown that these vaccines are safe. For the best protection, three doses of the vaccine should be given to girls before they are ever exposed to HPV. Most girls are exposed to HPV soon after they start having sex. The vaccine may not work as well in girls who have already had sex.

The American Cancer Society Recommendations

• Cervical cancer is caused by a sexually transmitted virus called the human papillomavirus (HPV). HPV is very common, but most HPV infections will not lead to cancer.

• All girls should be vaccinated against HPV at age 11 to 12 years.

• Women who are vaccinated still need to continue routine testing.

• Women 19 to 26 years old should talk to their doctor or nurse about whether to get this vaccine.

• The vaccine can be given to girls as young as 9 years.

• New HPV vaccines can prevent most (about 70%) cervical cancers.

• The vaccine is also recommended for girls 13 to 18 years old to catch up missed vaccine or complete the 3 doses needed.

HPV and Cervical Cancer

• The vaccine is not recommended for women over age 26 years or for boys or men.

Infection with certain types of HPV may lead to changes in the cells of the cervix. Certain changes, called high-grade cell changes, may progress to cervical cancer if not treated. Most HPV infections go away by themselves and cause no symptoms or cell changes. Having regular Pap tests can find these cell changes before they progress to cancer. If found, these cell changes can be treated. This can prevent them from becoming cervical cancer.

• All women who receive the vaccine should continue to have routine Pap tests because the vaccine protects against only the HPV types that cause about 70% of cervical cancers.

HPV Vaccines Recently, vaccines against the most common types of HPV that cause about 70% of all cervical cancers have been developed. Research has shown that HPV vaccines prevent infections from these types of HPV and also prevent highgrade cell changes caused by these types of HPV.

©2013 American Cancer Society, Inc. doi:10.3322/canjclin.57.1.29.

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Guidelines for Colonoscopy Surveillance after Polypectomy: A Consensus Update by the US Multi-Society Task Force on Colorectal Cancer and the American Cancer Society ABSTRACT

Adenomatous polyps are the most common neoplastic findings uncovered in people who undergo colorectal screening or have a diagnostic workup for symptoms. It was common practice in the 1970s for these patients to have annual follow-up surveillance examinations to detect additional new adenomas as well as missed synchronous adenomas. As a result of the National Polyp Study report in 1993, which demonstrated clearly in a randomized design that the first postpolypectomy examination could be deferred for 3 years, guidelines published by a gastrointestinal consortium in 1997 recommended that the first follow-up surveillance be 3 years after polypectomy for most patients. In 2003, these guidelines were updated, colonoscopy was recommended as the only follow-up examination, and stratification at baseline into lower and higher risk for subsequent adenomas was suggested. The 1997 and 2003 guidelines dealt with both screening and surveillance. However, it has become increasingly clear that postpolypectomy surveillance is now a large part of endoscopic practice, draining resources from screening and diagnosis. In addition, surveys have demonstrated that a large proportion of endoscopists are conducting surveillance examinations at shorter intervals than recommended in the guidelines. In the present paper, a careful analytic approach was designed addressing all evidence available in the literature to delineate predictors of advanced pathology, both cancer and advanced adenomas, so that patients can be more definitely stratified at their baseline colonoscopy into

24 American Cancer Society Guidelines

those at lower or increased risk for a subsequent advanced neoplasia. People at increased risk have either three or more adenomas, or high-grade dysplasia, or villous features, or an adenoma ≥1 cm in size. It is recommended that they have a 3-year follow-up colonoscopy. People at lower risk who have one or two small (<1 cm) tubular adenomas with no high-grade dysplasia can have a follow up in 5 to 10 years, whereas people with hyperplastic polyps only should have a 10-year follow up as average-risk people. Recent papers have reported a significant number of missed cancers by colonoscopy. However, high-quality baseline colonoscopy with excellent patient preparation and adequate withdrawal time should minimize this and reduce clinicians’ concerns. These guidelines were developed jointly by the US MultiSociety Task Force on Colorectal Cancer and the American Cancer Society to provide a broader consensus and thereby increase utilization of the recommendations by endoscopists. Adoption of these guidelines nationally can have a dramatic impact on shifting available resources from intensive surveillance to screening. It has been shown that the first screening colonoscopy and polypectomy produces the greatest effects on reducing the incidence of colorectal cancer in patients with adenomatous polyps. Winawer, S. J., Zauber, A. G., Fletcher, R. H., Stillman, J. S., O’Brien, M. J., Levin, B., Smith, R. A., Lieberman, D. A., Burt, R. W., Levin, T. R., Bond, J. H., Brooks, D., Byers, T., Hyman, N., Kirk, L., Thorson, A., Simmang, C., Johnson, D. and Rex, D. K. (2006), Guidelines for Colonoscopy Surveillance after Polypectomy: A Consensus Update by the US Multi-Society Task Force on Colorectal Cancer and the American Cancer Society,. CA: A Cancer Journal for Clinicians, 56: 143–159. doi: 10.3322/canjclin.56.3.143

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CA: A Cancer Journal for Clinicians

Guidelines for Colonoscopy Surveillance after Cancer Resection: A Consensus Update by the American Cancer Society and US Multi-Society Task Force on Colorectal Cancer ABSTRACT

Patients with resected colorectal cancer are at risk for recurrent cancer and metachronous neoplasms in the colon. This joint update of guidelines by the American Cancer Society (ACS) and US Multi-Society Task Force on Colorectal Cancer addresses only the use of endoscopy in the surveillance of these patients. Patients with endoscopically resected Stage I colorectal cancer, surgically resected Stage II and III cancers, and Stage IV cancer resected for cure (isolated hepatic or pulmonary metastasis) are candidates for endoscopic surveillance. The colorectum should be carefully cleared of synchronous neoplasia in the perioperative period. In nonobstructed colons, colonoscopy should be performed preoperatively. In obstructed colons, double contrast barium enema or computed tomography colonography should be done preoperatively, and colonoscopy should be performed 3 to 6 months after surgery. These steps complete the process of clearing synchronous disease. After clearing for synchronous disease, another colonoscopy should be performed in 1 year to look for metachronous lesions. This recommendation is based on reports of a high incidence of apparently metachronous second cancers in the first 2 years

after resection. If the examination at 1 year is normal, then the interval before the next subsequent examination should be 3 years. If that colonoscopy is normal, then the interval before the next subsequent examination should be 5 years. Shorter intervals may be indicated by associated adenoma findings (see Postpolypectomy Surveillance Guideline). Shorter intervals are also indicated if the patient’s age, family history, or tumor testing indicate definite or probable hereditary nonpolyposis colorectal cancer. Patients undergoing low anterior resection of rectal cancer generally have higher rates of local cancer recurrence, compared with those with colon cancer. Although effectiveness is not proven, performance of endoscopic ultrasound or flexible sigmoidoscopy at 3- to 6-month intervals for the first 2 years after resection can be considered for the purpose of detecting a surgically curable recurrence of the original rectal cancer. Rex, D. K., Kahi, C. J., Levin, B., Smith, R. A., Bond, J. H., Brooks, D., Burt, R. W., Byers, T., Fletcher, R. H., Hyman, N., Johnson, D., Kirk, L., Lieberman, D. A., Levin, T. R., O’Brien, M. J., Simmang, C., Thorson, A. G. and Winawer, S. J. (2006), Guidelines for Colonoscopy Surveillance after Cancer Resection: A Consensus Update by the American Cancer Society and US Multi-Society Task Force on Colorectal Cancer. CA: A Cancer Journal for Clinicians, 56: 160–167. doi: 10.3322/canjclin.56.3.160

Postcancer Resection Surveillance Colonoscopy Recommendations 1. Patients with colon and rectal cancer should undergo high quality perioperative clearing. In the case of nonobstructing tumors, this can be done by preoperative colonoscopy. In the case of obstructing colon cancers, computed tomography colonography with intravenous contrast or double contrast barium enema can be used to detect neoplasms in the proximal colon. In these cases, a colonoscopy to clear the colon of synchronous disease should be considered 3 to 6 months after the resection if no unresectable metastases are found during surgery. Alternatively, colonoscopy can be performed intraoperatively. 2. Patients undergoing curative resection for colon or rectal cancer should undergo a colonoscopy 1 year after the resection (or 1 year following the performance of the colonoscopy that was performed to clear the colon of synchronous disease). This colonoscopy at 1 year is in addition to the perioperative colonoscopy for synchronous tumors. 3. If the examination performed at 1 year is normal, then the interval before the next subsequent examination should be 3 years. If that colonoscopy is normal, then the interval before the next subsequent examination should be 5 years. 4. Following the examination at 1 year, the intervals before subsequent examinations may be shortened if there is evidence of hereditary nonpolyposis colorectal cancer or if adenoma findings warrant earlier colonoscopy.1 5. Periodic examination of the rectum for the purpose of identifying local recurrence, usually performed at 3- to 6-month intervals for the first 2 or 3 years, may be considered after low anterior resection of rectal cancer. The techniques utilized are typically rigid proctoscopy, flexible proctoscopy, or rectal endoscopic ultrasound. These examinations are independent of the colonoscopic examinations described above for detection of metachronous disease. Winawer SJ, Zauber AG, Fletcher RH, et al. Guidelines for colonoscopy surveillance after polypectomy: a consensus update by the US MultiSociety Task Force on Colorectal Cancer and the American Cancer Society. CA Cancer J Clin 2006; 56: 143–159.

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CA: A Cancer Journal for Clinicians

American Cancer Society Guidelines for Breast Cancer Screening: Update 2003 ABSTRACT

In 2003, the American Cancer Society updated its guidelines for early detection of breast cancer based on recommendations from a formal review of evidence and a recent workshop. The new screening recommendations address screening mammography, physical examination, screening older women and women with comorbid conditions, screening women at high risk, and new screening technologies.

Smith, R. A., Saslow, D., Sawyer, K. A., Burke, W., Costanza, M. E., Evans, W. P., Foster, R. S., Hendrick, E., Eyre, H. J. and Sener, S. (2003), American Cancer Society Guidelines for Breast Cancer Screening: Update 2003. CA: A Cancer Journal for Clinicians, 53: 141â&#x20AC;&#x201C;169. doi: 10.3322/canjclin.53.3.141

View more information on the following Patient Page

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PATIENT PAGE Finding Breast Cancer Early Breast Cancer Facts • The American Cancer Society estimates that this year, 211,300 women will develop invasive breast cancer in the United States and 39,800 women will die of the disease. Breast cancer is the second leading cause of cancer death in women. • Besides being female, age is a woman’s single most important risk factor for developing breast cancer. Nearly half of all new breast cancers occur in women over the age of 65. • Women with more than one relative who has had breast cancer or with one or more relatives who were diagnosed at a young age have a higher risk of breast cancer and should talk to their doctor or a specialist about their risk.

Benefits of Finding Breast Cancer Early (Early Detection) The earlier breast cancer is found, the better the chances for successful treatment. Because most cases of breast cancer cannot be prevented, finding breast cancer early and treating it are the most important strategies in preventing deaths from the disease and decreasing the chance of having to remove the breast.

Mammograms Right now, a mammogram is the best way to find breast cancer at an early stage, when treatment is highly successful. A mammogram can find breast changes that may be cancerous years before physical symptoms develop. Results from over 40 years of research clearly show that women who have regular mammograms are more likely to have their breast cancer found early. Mammograms are not perfect.They miss some cancers. Also, doctors sometimes recommend tests in addition to a regular mammogram to find out whether something found in a mammogram is or is not cancer.These additional tests can often be stressful. It is important that women having mammograms know what to expect and understand these possibilities. A mammogram, despite limitations, remains a very effective and valuable tool for decreasing suffering and deaths from breast cancer. Most women will never develop breast cancer, but for many women it is an important health problem and concern. Getting mammograms every year starting at age 40 is the most important thing a woman can do to find breast cancer

at an early stage and have the best chances of successful treatment.

Examining the Breasts Breast cancer will sometimes, but not always, be found by breast self-exam (BSE) or clinical breast exam (CBE) by a doctor. But in order to save lives, the exams must find the breast cancer as early as possible. Research has not shown that regular breast exams by either a health professional or by yourself (BSE) will find breast cancer early enough to save lives. Nor has research definitely ruled out any benefit of doing these exams. But because of the clear connection between the size of breast tumors and the chances for successful treatment, and because mammograms will not find all breast cancers, regular physical examination of the breasts by a health care professional (CBE) is recommended. The American Cancer Society also recommends that health care professionals offer instructions to their patients in BSE so that women can become familiar with how their breasts feel.The health professionals should also explain the possible benefits and limitations of BSE so that women can make an informed decision about whether or how often to do BSE.

American Cancer Society Recommendations For Women in Their 20s and 30s If you are in your 20s or 30s, your risk of breast cancer is very low. But because a small number of young women do develop breast cancer, it is important to have a CBE as part of a periodic health examination, preferably at least every three years, and to become familiar with how your breasts normally feel. BSE can help you become familiar with how your breasts normally feel. Knowing what is normal for you is important so that if you notice a difference at any time (while dressing, bathing, etc.) you can contact your doctor. If you choose to do BSE, the health professional you see for regular care can show you how, check to see that you are doing it correctly, answer any questions, and explain the importance of promptly reporting any new breast symptoms or problems. It is also okay to choose not to do BSE, or to do BSE but not every month.

For Women Aged 40 and Over At age 40, you should begin to have a mammogram every year. As long as you are in reasonably good health, you should continue to have mammograms. continued on next page

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Finding Breast Cancer Early, Con’t. Age alone should not be the reason to stop having regular mammograms. However, if you have severe health problems that are likely to shorten your life, you and your doctor may want to discuss stopping. You should also have a CBE as part of a periodic health examination, preferably every year. You should have the CBE shortly before you have your mammogram.This way, any abnormal areas that might be found by the CBE can be reviewed more carefully in the mammogram. Report any breast symptoms or breast problems to your doctor immediately.

For Women at Increased Risk of Breast Cancer Women who have a higher than average risk of developing breast cancer may benefit from starting early detection practices at a younger age or having additional tests or more frequent examinations. Factors that help determine if a woman is at high risk include: • a strong family history of breast cancer (especially if their mother, sister, or daughter developed breast cancer at a young age or if several close relatives have breast or ovarian cancer). • genetic tests that showed changes in the BRCA1 or BRCA2 breast cancer genes. • a breast cancer treated in the past.

• radiation therapy in the chest area for another type of cancer. There is not enough research yet on the value of screening women younger than 40 with mammograms or with other tests such as magnetic resonance imaging and ultrasound. Some doctors may recommend these tests for women with the above risk factors. If you think you are at higher risk based on the factors above, talk to your doctor about what is known about these tests and their potential benefits, limitations, and harms. Then make a decision together about the testing that is best for you.

©2013 American Cancer Society, Inc. doi:10.3322/canjclin.53.3.170.

28 American Cancer Society Guidelines

Tips for a Better Mammogram • Bring a list of the places and dates of mammograms, biopsies, or other breast treatments you have had before.

• If you have had mammograms at another facility, you should make every attempt to get those mammograms so that they are available to the radiologist at the current examination.

• On the day of the examination, do not wear deodorant; this can interfere with the mammogram by appearing on the x-ray film as spots. • If your breasts are tender the week before your period, you should avoid mammograms during this time. The best time for you to have a mammogram is one week after your period.

• You should describe any breast symptoms or problems that you are having to the technologist performing the examination. Be prepared to tell the person doing the mammogram (mammography technologist) about hormone use, family or personal history of breast cancer, and any prior surgeries.You should also discuss any changes or problems in your breasts with your doctor or nurse before having a mammogram.

• If you do not hear from your doctor within 10 days, do not assume that your mammogram was normal—call your doctor or the facility.

For more information about mammograms, finding breast cancer early, or about breast cancer, please visit our Web site at www.cancer.org or contact your American Cancer Society at 1-800-ACS-2345 day or night.

CA

A Cancer Journal for Clinicians

Wiley-Blackwell

CA

A Cancer Journal for Clinicians

The American Cancer Society Guidelines and Patient Pages are published in CA: A Cancer Journal for Clinicians. The journal offers a host of content that enables you to stay abreast of the latest oncology information essential for clinicians working on the frontlines of the battle against cancer.

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The American Cancer Society is the nationwide, community-based, voluntary health organization dedicated to eliminating cancer as a major health problem by preventing cancer, saving lives, and diminishing suffering from cancer, through research, education, advocacy, and service. For further information on the American Cancer Society, please visit www.cancer.org.

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Meet the Editors Otis Webb Brawley, MD Recognized by Castle Connelly Medical, Ltd. as one of America’s Top Doctors for Cancer, Otis Webb Brawley is the Chief Medical Officer and Executive Vice President of the American Cancer Society. He is also Editor-in-Chief of CA: A Cancer Journal for Clinicians. He is responsible for promoting cancer prevention, early detection, and quality treatment through cancer research and education, championing a variety of efforts, including initiatives to decrease smoking, improve diet, and enhance the ACS’s advocacy programs. Moreover, he is a leader in the Society’s efforts to eliminate disparities in access to quality cancer care. Dr. Brawley also serves as Professor of Hematology, Oncology, Medicine, and Epidemiology at Emory University.

Ted Gansler, MD, MBA, MPH As Director of Medical Content at the American Cancer Society, Ted Gansler heads the ACS Continuing Professional Education program, and provides medical and scientific review of information for patients and the general public. He is also Editor of CA: A Cancer Journal for Clinicians. Dr. Gansler’s recent research has explored cancer-related health literacy and attitudes, the use of complementary therapies by cancer survivors, outcomes of patient education interventions, and measures of healthcare quality. Prior to joining the ACS, Dr. Gansler directed the Cytopathology Laboratory and Cytopathology Fellowship Program at Emory University, where he is currently an Adjunct Associate Professor of Pathology.

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A Cancer Journal for Clinicians

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American Cancer Society - Guidelines and Patient Pages