Medical screening

There is an old joke that asks, How do you get to Carnegie Hall?

The answer, of course: practice, practice, practice.

While Dr. Gopala Ramineni’s advice for cancer prevention and detection sounds like a new refrain to the same tune — a No. 1 hit played by doctors around the country — it is certainly no joke.

“Screenings, screenings, screenings,” Ramineni says. “It is far easier to treat in early stages. That’s why it’s so important.”

Ramineni, who works with Indiana Regional Medical Center in Western Pennsylvania, lives by the phrase “a stitch in time saves nine,” and he hopes his patients do, too. As with most problems, procrastinating when it comes to cancer screenings can only lead to more issues down the road.

“When we catch them Stage 1 and Stage 2 — cancers — they’re easier to manage,” Ramineni says. “Screening improves survival and it does improve cancer-free living.”

The survival rate for those diagnosed with Stage 1 breast cancer is 92 percent, for instance. But survival numbers drop and symptoms increase as cancers are found in later stages, Ramineni says.

“I don’t want to see a patient with Stage 3,” Ramineni says. “I want everybody to be diagnosed at Stage 1 and 2, and the only way to do it is screenings.”

Ramineni says when there are overt signs of cancer, the opportunity to sew that stitch in time may have already passed.

“When you have a symptom from cancer, it’s probably too late,” Ramineni says.

The following guide outlines screening recommendations for some of the most common cancers, expert insights on the importance of early detection, advances in testing and treatment, genetic factors, other risks, symptoms and more.

Breast Cancer

Female breast cancer ranked No. 1 in 2017 for highest rates of new cases, with 125.1 diagnoses for every 100,000 people in the United States, according to the most recent data from the Centers for Disease Control and Prevention. It was the second-most deadly, with 19.9 deaths recorded per 100,000 people.

The United States Preventive Services Task Force recommends women ages 50-74 with an average risk for breast cancer get a mammogram every two years. But women 40-49 years old should still talk to their doctors about when to start screenings and how often.

Dr. Dan Clark, who specializes in surgeries for breast and colorectal cancers with the Indiana Regional Medical Group in Western Pennsylvania, said he prefers to follow recent recommendations that women start mammograms as young as 40.

“There has been significant improvement with the survival of women ages 40-50 if mammography is done at 40,” Clark says. “[But] there’s a huge difference if you have a family history.”

In the case of family history, Clark said it is strongly advised that women start screenings 10 years younger. In addition to mammograms, all women should conduct self-exams monthly.

While it is also possible for men to get breast cancer, the disease affects women in much larger numbers. Only 1-2 percent of men are likely to get it, unless they have a strong family history, while the average woman who lives until 90 has a 13.5 percent chance of encountering the disease at some point in her life.

Clark says obesity, a lack of physical activity, excessive use of alcohol, diets high in fat and dense breasts also can increase the risk of cancer. For women at high risk, he says he sometimes recommends a combination of mammography and MRI, which can be complementary and catch different things.

No matter what the risk, staying on top of screenings can be vital.

“The earlier you make a diagnosis, the better the outcome,” Clark adds.

While some people show no symptoms, warning signs are a new lump in the breast or armpit; thickening or swelling of part of the breast; irritation or dimpling of breast skin; redness or flaky skin in the nipple area or the breast; pulling in of the nipple or pain in the nipple area; nipple discharge other than breast milk, including blood; any change in the size or the shape of the breast; and pain in any area of the breast, according to the CDC.

Symptoms can occur with other conditions that are not cancer, though, as is the case with the cancers that follow. People should consult a physician if they are experiencing any issues.

Other risk factors for breast cancer include getting older, genetic mutations, reproductive history, a personal history of breast cancer or certain non-cancerous breast diseases, a family history of breast cancer, previous treatment using radiation therapy, and women who took the drug diethylstilbestrol. There are also changeable risk factors, including taking hormones and drinking alcohol, according to the CDC.

Colorectal Cancer

Cancers of the colon and rectum are the fourth most prevalent and deadly in the U.S., with 36.8 people diagnosed with it for every 100,000, and 13.5 out of 100,000 dying from the cancers, CDC data shows.

Clark says colon cancer screening recommendations were recently reduced from 50 to 45 for the average person. The drops in ages for screening largely represent trends in when these types of cancers are most commonly appearing.

“We’ve seen a drop in the age of colon cancers,” Clark says. “If they have a genetic link, family history, that all changes.”

When there is a family history, Clark recommends people start getting screened 10 years younger than when the family member was diagnosed. That is because colon cancer typically starts as polyps, which take an average of five years to develop into cancer. Catching those early means simpler and more successful treatment, Clark says.

“For the average person, the vast majority can be removed with colonoscopy before it develops into cancer,” he explains. “By the time you have symptoms, it’s usually a more advanced cancer.”

That said, Clark says people should pay special attention if they notice “pencil thin” stool or see any brightness in their stool. The CDC also notes stomach pain, aches and cramps that stick around, as well as unexplained weight loss, as possible signs of colorectal cancer.

“Anyone over the age of 40 who has blood in their stool should get an exam,” Clark says.

Ramineni adds that part of the problem with colon cancer is that doctors still have a hard time getting some men to make regular appointments and submit to screenings on a scheduled basis.

“Women are more likely to be compliant than men,” Ramineni says.

There may be concerns about the process that keeps men away from colonoscopies. To those men, Ramineni said it is not as bad as they think — he recently got his — and it is of life-and-death importance.

“Colonoscopy is not that invasive,” Ramineni says. “Yes, there is inconvenience, but the risks are minimal compared to cancer.”

Several stool tests, flexible sigmoidoscopy and CT colonography may also be options, and the CDC recommends patients consult with their physicians about which option or options are best for them.

Clark adds that obesity and diets high in fat are also risk factors for colon cancer. Black patients tend to run a higher risk. Underlying conditions, such as irritable bowel syndrome, can increase the percentages, as well.

The CDC adds that diets high in fruits, vegetables and whole grains that reduce the risk of other chronic diseases may also reduce the risk of colorectal cancer. Low-dose aspirin can help prevent colorectal cancer in some adults. Some studies show that increasing physical activity, limiting alcohol consumption and avoiding tobacco can help reduce risks.

Clark says there is good news when it comes to battling colon cancer. In recent years, robotic surgeries have cut down drastically on hospital and recovery times — from 1-2 weeks in the hospital to 2-3 days, and months of home recovery down to two weeks. What that means is not just a more comfortable process for patients, but in the unfortunate case that a cancer spreads, it allows physicians to start life-saving treatments such as chemotherapy sooner than they could in the past while waiting for open wounds to heal.

HPV & Cervical Cancer

“Cervical cancer is not like other cancers,” Dr. Teresa Diaz-Montes says. She specializes in gynecologic oncology at Mercy Medical Center in Baltimore.

That is to say that cervical cancer is not usually associated with genetic causes. Instead, it typically stems from human papillomavirus (HPV) — “almost all” cases of cervical cancer are caused by HPV, according to the CDC — to which Diaz-Montes says roughly 80 percent of sexually active people in the United States have at some point been exposed.

Despite this, cervical cancer numbers here have gotten better.

“Cervical cancer used to be a big problem,” Diaz-Montes says. “Now, cervical cancer is not as common as before.”

A big part of that has been screenings and early patient care, she says. But problems still exist, in part because virtually symptomless cases of HPV can make it hard for some to understand the virus. While the vaccine available now “covers more types of viruses than it used to” in an effort to prevent against the strains that most commonly develop into cancers, the vaccine does not prevent all 100-plus strains. People could be exposed and contract HPV even when they think they are completely protected, Diaz-Montes says. Those vaccinated should still get regular screenings.

“Education is key,” she insists. “A lot of people still don’t know about HPV and cancer.”

Diaz-Montes says pap screenings are recommended starting at age 21 for women — regular screening methods are not recommended for most men, according to the CDC — and should take place annually until the age of 65, as long as they come back without problems. As with other cancers, there are drugs available for advanced-stage cervical cancer, but Diaz-Montes says they always hope to catch it early.

“If a patient has early stage cervical cancer, we try to manage it surgically,” she says.

People get the HPV vaccine, on average, around age 12, but Diaz-Montes says it generally can be given anywhere from ages 9-26. She recommends thinking about it early, as it does the most good before people become sexually active.

“Basically, the earlier the better,” she says.

Diaz-Montes cautions that HPV can cause other problems, too.

“HPV doesn’t just affect the cervix,” she says. “People need to understand if they are exposed to HPV, it’s not just the cervix at risk. All types and parts of the body could be at risk.”

Each year, roughly 44,000 new cases of cancer are found in parts of the body where HPV is found, according to the CDC. HPV has been determined as the cause for approximately 34,800 of those cancers.

Roughly 40 types of HPV can be spread through direct sexual contact to genital areas, as well as the mouth and throat, according to the CDC. Oral HPV is transmitted to the mouth by oral sex and possibly in other ways. Most people are clear of HPV within two years, but it persists in others, per the CDC.

People also can help prevent cervical cancer by not smoking, using condoms during sex and limiting the number of sexual partners they have, the CDC says. HIV, using birth control pills for five or more years, and giving birth to three or more children also can increase the risk of cervical cancer. Early cases of cervical cancer may not show symptoms, but advanced cancer may cause bleeding or discharge from the vagina that is not normal for the individual.

Prostate Cancer

Prostate cancer is the second most-prevalent type of cancer in the U.S. — and the most common among American men, not including skin cancers — with 106.5 out of every 100,000 people being diagnosed with it, according to the CDC. It ranks third in terms of deaths, with it claiming the lives of 18.9 people in every 100,000.

There are almost 200,000 new cases diagnosed each year, with more than 30,000 deaths from the disease, making it the second leading cause of cancer death in American men after lung cancer, according to Dr. Damon Davis, a surgeon with The Urology Specialists of Maryland at Mercy Medical Center in Baltimore. He says there is a 1 in 9 lifetime chance of developing prostate cancer, and a 1 in 40 chance of dying from it.

“Early detection is crucial, since prostate cancer can only be managed, and not cured, once the disease has spread widely,” Davis says. “Early detection and treatment of the disease when it is still confined to the prostate offers the best chance at long-term cure.”

Davis says regular screenings for prostate cancer are recommended by most urologists, but there is some debate about the starting age. He suggests starting at 40 for African-American men with a family history of prostate cancer, and 45 for African-American men without that family history. All other men should start at 50 without a family history, or 45 with one, he says.

Smoking is also considered a risk factor for prostate cancer.

The CDC notes men should talk with their doctors about benefits and potential harms of screening for prostate cancer. Possible screenings include a prostate specific antigen test and digital rectal examination.

Davis notes that new screening tests have been introduced in recent years, including some that use blood and others that use urine to detect genetic markers. Getting tested is a necessity.

“Prostate cancer typically has no symptoms until the disease has progressed very far,” he says. “So, early diagnosis of disease with prostate cancer screening is crucial.”

Advances in surgery and radiation have helped decrease morbidity rates and side effects from treatments for prostate cancer. Similar to colon cancer, robotic-assisted surgery has decreased hospital stays and recovery time at home. Davis says.

The CDC notes age is the biggest risk factor for prostate cancer, as risk increases with age. African-American men are more likely to get prostate cancer than other men, more than twice as likely to die from it as white men, get it younger, have a more advanced form when it is found, and have a more severe type than white men, per the CDC.

Symptoms may include difficulty starting urination; weak or interrupted flow of urine; frequent urination, especially at night; difficulty emptying the bladder completely; pain or burning during urination; blood in the urine or semen; pain in the back, hips, or pelvis that does not go away; and painful ejaculation.

Skin Cancers

Melanomas of the skin are sixth on the list of most prevalent cancers in the United States, with 22.7 new cases for every 100,000 people, according to the CDC. Thankfully, they do not break the top 10 in terms of deaths.

Still, skin cancer is nothing to take lightly. While screenings are not handled with the type of systemic regularity of cancers of the breast or colon, prevention efforts are a “huge and very important topic,” according to Dr. Vadim Gushchin, a surgeon who specializes in melanoma treatment, as well as abdominal and colorectal cancers at Mercy Medical Center.

The sun remains the worst enemy when it comes to skin cancer, especially as it relates to melanoma. The problem is it can be difficult to convince people that too much sun can be a bad thing.

“It’s difficult to vilify sun exposure,” Gushchin explains. “It never seems dangerous to us.”

In particular, he cautions parents to make sure they are careful about exposing their children to too much sun before the age of 15, when it can have long-lasting effects.

“The earlier it is, the more pronounced the damage,” Gushchin says, noting that does not mean sun exposure should be a free-for-all after 15 years old.

People should avoid direct sunlight on the skin whenever possible, especially between the hours of 10 a.m. and 4 p.m. (on average, though times vary across the year); wear wide-brimmed hats; find protective clothing with an SPF of 30 or higher; and use sunglasses regularly.

Sunscreen, while the most popular solution to sun exposure, is a double-edged sword, Gushchin says. While the SPF in sunscreen can be protective, too many people fail to apply it correctly to make it as proven a method of preventing melanoma as other options. He does not specifically advise against it, but prefers people take other measures to protect themselves.

The CDC notes people using sunscreen should apply a thick layer of broad spectrum sunscreen with an SPF of 15 or higher at least 15 minutes before going outside, even on cloudy or overcast days, and then reapply it at least every 2 hours, and after swimming, sweating, or using a towel. Indoor and outdoor tanning alike are discouraged, to help reduce UV exposure.

The CDC also recommends paying attention to the UV Index provided by the National Weather Service and the Environmental Protection Agency to avoid high risks. People should keep an eye on moles that have different colorizations, jagged edges, are larger than the size of a pea, or change over a short period of time.

Gushchin says there are family predispositions to melanoma, but they may be more behavioral than genetic — families tend to go on the same summer vacations, pick up similar habits, etc. Either way, anyone with family predispositions should be seen by a dermatologist more often, Gushchin says.

He also says people with fair skin, blue eyes and red hair — generally people of northern European heritage — could have predispositions to skin cancer, especially if they have moved farther south. The CDC adds freckles, skin that reddens easily, green eyes, blond hair and older age to that list. And those with atypical birthmarks have higher risks of developing melanoma and should be screened by a dermatologist on a regular basis, Gushchin says.

“The strategy to do screenings in those high-risk people is more productive,” he adds.

According to the CDC, nearly 5 million people are treated for skin cancer every year in the United States. The CDC reminds that tans do not indicate good health but damage to the skin. Every time people tan, they are increasing their risk of skin cancer.

A few more notes

Genetic counseling — something in which Clark specializes — has made big advances in cancer prevention. Some people with high cancer risks choose to do prophylactic surgeries, such as having breasts or ovaries removed, to prevent cancer from developing.

But in general, screenings remain key to the aforementioned cancers when it comes to early detection and survival. They undoubtedly help increase survival rates, and help those who survive to live longer and happier cancer-free lives.

Clark says the good news is that cancer screenings are on the rise, largely thanks to advertisements and articles such as this. Death rates associated with certain cancers have been dropping for years — such as fatalities related to breast cancer, which have dropped steadily since 1989.

Ramineni adds that most screening facilities are covered by insurance, but there is help out there, too, for the uninsured to make sure they can keep up on regular screenings.

For more information about the cancers addressed here, a variety of others and national data, visit cdc.gov/cancer.