A side-by-side review of cancer screening guidelines from the American Cancer Society (ACS) and the US Preventive Services Task Force (USPSTF) anchored a presentation on cancer screening and barriers that increase health disparities for specific populations. Tracy Wyant, DNP, AOCN, CHPN, GERO-BC, EBP-C, CPPS, senior director of medical content, and Tracy Wiedt, MPH, managing director of health equity, both with the American Cancer Society, Patient Support, started their presentation with an explanation of how guidelines are developed and updated.
The review focused on screening recommendations for persons at average to high risk of breast, colorectal, cervical, lung, prostate, and skin cancers. Average risk is defined differently depending on the type of cancer, but generally indicates that the individual has no personal history of the cancer, no strong family history of the cancer, and no genetic mutation or condition known to increase risk for the disease (eg, BRCA mutation for breast and cervical cancers, Lynch syndrome and others for colorectal cancer).
All women should be counseled to be familiar with the benefits, limitations, and potential harms associated with breast cancer screening; know how their breasts normally look and feel; and report any changes in their breasts to their health care provider.
Recommendations from the ACS suggest patients undergo an annual mammography, whereas USPSTF recommends biennial screening; both suggest the screening as an option for the youngest persons covered by their recommendations (40 to 44 years and 40 to 49 years, respectively).
The ACS recommends annual mammography for persons aged 45 to 54 years, and biennial screening at 55 years and older. Screening should continue for those in good health and have a life expectancy of at least 10 more years. No recommendations are made for clinical examination at any age.
USPSTF recommends undergoing biennial screening mammography for those ages 50 years to 74 years. No screening is recommended for persons older than 75 years.
Persons at high risk should undergo screening with MRI along with an annual mammography, according to ACS guidelines; whereas, USPSTF guidelines suggest those at high risk may benefit from beginning screening in their 40s.
Guidelines have been adjusted to reflect the increasing prevalence of colorectal cancer in younger persons. Both ACS and USPSTF guidelines recommend regular screening from age 45 through age 75 for persons at average risk. Screening in persons aged 76 to 85 should be based on patients’ preferences, overall health, and screening history. No further screening is recommended for those older than 85. Persons at high risk should consult with their health care provider.
Use of sensitive stool-based tests and visual examinations are similar between the guidelines, with slight differences in recommended frequency of screening. For stool-based tests, both recommend fecal immunochemical test (FIT) every year or FIT-sDNA every 3 years (ACS) or every 1 to 3 years (USPSTF).
The ACS and USPSTF recommended screening frequency for visual examination is colonography every 3 years and every 5 years; flexible sigmoidoscopy every 5 years and every 5 years or every 10 years with an annual stool test (USPSTF), respectively. Both guidelines recommend colonoscopy every 10 years. Abnormal test results need to be followed up with a colonoscopy.
Recommendations suggest no cervical cancer screening for women younger than 25 years (ACS) or 21 years (USPSTF) because cervical cancer is rare in this population. Women vaccinated for HPV should follow recommendations.
For women older than 65, the ACS recommends discontinuing cervical cancer screening in those with normal results for the past 10 years. In addition, screening can be discontinued in those whose cervix was removed for a noncancer-related reason. However, screening should continue in women with a history of a serious precancer condition for 25 years after discovery of the condition.
Age older than 65 and post hysterectomy are criteria for discontinuing cervical cancer screening, according to USPSTF recommendations.
USPSTF recommends Pap test every 3 years for women ages 21 to 29. Both guidelines recommend primary HPV every 5 years or HPV/Pap co-test every 5 years or Pap test every 3 years, but differ by age group. ACS makes this recommendation for women ages 25 to 65, whereas USPSTF makes this recommendation for women ages 30 to 65.
The ACS is currently updating its recommendations for lung cancer screening. It advises people at increased risk of lung cancer to follow the recommendations from the USPSTF, the American Academy of Family Physicians (AAFP), or the American College of Chest Physicians.
USPSTF guidelines recommend annual low-dose computed tomography (LDCT) for persons at increased risk of lung cancer. Criteria for LDCT include age 50 to 80 years, 20-pack year smoking history, and current smoker or has quit smoking within the past 15 years. Screening should be discontinued once a person has not smoked for 15 years, or if they develop a problem that substantially limits their life expectancy or the ability or willingness to undergo curative lung surgery.
Neither the ACS nor USPSTF have specific recommendations for prostate cancer screening. Both guidelines advise counseling men aged 55 to 69 on whether to undergo testing, the benefits and harms of testing, and their personal risk, incorporating personal history, family history, race/ethnicity, and treatments and outcomes. Men older than 70 should not undergo screening.
The ACS and USPSTF guidelines recommend counseling patients on risky behaviors, such as minimizing exposure to UV radiation. The ACS recommends encouraging patients to perform a monthly skin self-exam, but the USPSTF does not include such a recommendation.
Social determinants of health can significantly influence the likelihood of people in marginalized groups to access preventive care such as cancer screenings. These include financial stability, access to and quality of education, access to and quality of health care, neighborhood and built environment, and social and community content. Specific communities likely to experience health care disparities are Black, indigenous, Hispanic and Latino, and LGBTQ+.
Rates of cancer screening are tied to access to care, medical mistrust, and employment. Insurance coverage is closely tied to employment; however, many people in marginalized groups have inadequate health insurance even though they have a job. Diagnoses are more likely to be advanced cancer in people with no health insurance.
The presenters suggested some key actions that could improve uptake of preventive measures and outcomes for these groups. Culturally and linguistically appropriate educational materials would help align clinical care and screening recommendations for these communities. Partnerships and community collaboration could lead to increased public awareness and measurable steps toward eliminating cancer health disparities.
Wyant T, Wiedt T. Cancer screening: current guidelines, challenges, and disparities. Oral presentation at: 2022 Oncology Nurse Advisor Summit; March 25-27, 2022.