In your Business with Dr. B: Screenings Screenings Screenings!

Dr. Rebecca Brightman talks us through which cancers women and men should make sure they get screened for

We all know that the best way to keep cancer at bay is to be screened early and often, but what does that mean exactly? Do screenings vary from person to person, and from cancer to cancer? We asked our resident women’s health expert, Dr. Rebecca Brightman, about how and when to mark your calendar to make sure you never miss another screening… and don’t worry guys, we made sure to cover cancers that only impact men, too! Dr. B’s biggest takeaway? Know your family history.

KCM: Let’s start with breast cancer screenings. When should women start getting mammograms?

Dr. Rebecca Brightman: The majority of medical societies recommend starting at age 40. I personally will start sending patients for mammograms at 35. We start breast surveillance earlier in people with family histories and people who have mutations, which increase the risk of breast cancer. Getting a family history of cancer is crucial, because the carrier screening panels available are constantly expanding. Many people may feel that if a relative was screened years ago they don’t need to be rescreened, but these panels are always updated. And even if someone screens negative, if there’s a strong family history, you still want to ramp up surveillance. That may mean getting a mammogram with an ultrasound, and frequently the addition of MRI screening. The majority of people who are diagnosed with breast cancer actually don’t have a family history, but for people with a known gene mutation, the surveillance is different.

If there is a family history of breast cancer, then as a rule of thumb, we tell people to get screened 10 years prior to the age at which the cancer was found in their relative. So if your mother got it at 40, you should get screened at 30. I’d recommend doing it even earlier, because let’s say your mom was diagnosed with cancer at 40, but it was a very advanced stage. You want to try to detect it even sooner. 

It’s also important to remember that you can inherit a gene mutation from your mother or your father. So when we take a family history, the father’s history is just as important. So when gathering a history of breast or ovarian cancer on your father’s side, you may have to go out a generation or two. 

When we discuss breast cancer screenings, it’s worthwhile noting that certain men should be screened for breast cancer as well. These are men with certain hereditary genetic mutations or with a family history of male breast cancer.

If you find out that you do test positive for the BRCA gene, how likely is it that you will develop breast cancer, and at what point might a woman consider getting an elective mastectomy?

The chances are around 20 to 30% that you will develop cancer, but BRCA1 and BRCA2 carry an increased risk of both breast and ovarian cancer. If you’ve been screened for BRCA1 and 2, and there’s a family history, there are other genes that can cause cancer which you should be screened for as well.

The decision to get an elective mastectomy depends on a woman’s carrier status and family history. It’s also a very, very personal choice. I see patients who have the mutation who may have a history of ovarian cancer but not breast, but they want mastectomies. It is such a personal decision. If I had to generalize, those with family members who have had cancers at very early ages and have a gene mutation are the ones who are more inclined to have prophylactic mastectomies or prophylactic ovariectomies, which is a procedure in which your ovaries are removed. But the decision has to be made based upon when a family member had cancer, and for an ovariectomy, if a woman desires to have children. But now with IVF, a woman can still bear a child even after having her ovaries removed.

Is there a specific screening for ovarian cancer?

There is not an established screening test for ovarian cancer, and sadly most people are diagnosed at stage three. However for people who are thought to be at increased risk, we typically do a transvaginal pelvic ultrasound every four to six months, combined with a blood test for tumor markers. But tumor markers are not exact, and we do not use these tests on anyone who is not at very high risk, because there are so many false positives. 

Let’s talk about colon cancer. Around what age should people start getting regular colonoscopies?

If you have a family history of colon cancer, you should get your first colonoscopy at least 10 years before the age that person was diagnosed. If there is no family history, then in the United States it’s recommended to get colon cancer screenings starting at age 50, but many doctors will recommend them at 45. Some of your readers may say “my internist said I can wait until I’m 50,” but having seen a handful of patients who have had early cancerous and precancerous polyps picked up with a colonoscopy, I am certainly not in favor of waiting.

A colonoscopy is the “gold standard” for colon cancer screenings, but it may not be appropriate for all patients. Some patients decline colonoscopies, and non-invasive screens are an option.  These involve annually checking stool for occult blood, and DNA-based screening of stool samples every 3 years, or at other indicated intervals. One should realize though that if the non-invasive screens are abnormal, the next step would be a colonoscopy.

We’ve spoken in the past about HPV and cervical cancer screenings, but can you refresh our memories on the timeline that women should start getting these?

Cervical cancer is not hereditary. It is due to HPV exposure, and typically anal cancers are as well. There is now a vaccine called Gardasil, which protects against the most aggressive forms of HPV. Even if a woman has been vaccinated, there are multiple HPV subtypes out there, so we start doing pap smears [cervical screenings used to detect signs of cancer or precancer, frequently caused by HPV] on women starting at age 21. By the book, you should get them until age 70, but if a woman over 70 has recently had an abnormal pap, or has a new sexual partner, I would still recommend getting them.

We know that men are carriers of HPV, but aren’t generally impacted by it because of course, they can’t get cervical cancer. But can men get anal cancer from HPV?

Absolutely. High risk populations include MSM (men who have sex with men) and particulalry men who are HIV+ or immunocompromized. For women, anal intercourse is not the only risk factor, and women who are infected with high risk HPV strains are at incrased risk for anal cancer. Unfortunately established screening guidelines for anal cancer do not exist, and screenings for high risk individuals are limited and involve obtaining a sample of anal cells, much in the same way a pap is performed. If these cells are abnormal, one would undergo an anoscopy, a procedure where the anal canal is examined for the presence of any areas that appear abnormal.  

And for men, when should they start being checked for prostate cancer?

I’m not a urologist of course, but these screenings start at around age 50, maybe a bit earlier if there’s a family history, but there is no established consensus. The decision as to when and how to screen for prostate cancer and at what intervals is debatable, but it can fall anywhere between the ages of 45 to 54. 

Like many of the cancers we’ve discussed, family history is very important with prostate cancer. If there is a strong family history, or if someone is known to carry a genetic mutation that puts them at high risk for prostate cancer, then screenings should start on the earlier side.  Screenings include the measurement of blood markers, as well as a prostate exam (digital rectal exam). As with some other cancers, the intervals at which screening should occur vary, and must be individualized and discussed with one’s health care provider.

How about skin cancer screenings?

The majority of sources agree that individuals at low risk of skin cancer should have an initial  screening exam between the age of 20 to 30.  Self skin exams are also important, and one should see a dermatologist if one notices a new and/or changing mole or a non-healing skin lesion. The frequency of skin checks should be made in concert with one’s dermatologist.  

Individuals at high risk should be examined at least every 12 months. High risk individuals are those who have a family history of melanoma, certain genetic predispositions, history of blistering sunburns, history of abnormal skin biopsies, or a personal history of skin cancer.  Individuals who are immunocompromised are also at higher risk of skin cancer. 

What about people who do not have access to their family history? Are there other indicators that you should get an early screening for any cancers?

The absence of a family history doesn’t mean a negative family history. If someone has zero family history, I will do genetic testing and a multi-gene panel. Many of my patients who are adopted have gotten their ancestry DNA done to get a better sense of their ethnic background. 

If somebody is ambivalent, genetic counseling is important, and it is available. 

This article was written and reported by Emily Pinto.