CANCER SCREENING AND NCCP

1. Cancer Screening and National
Cancer Control Programme
Dr Kiran Kumar BR
Moderator: Dr Amrut S Kadam

2. Outline
• Introduction
• Screening guidelines
Breast Cancer Screening
Cervical Cancer Screening
Colorectal Cancer Screening
Lung Cancer Screening
Prostate Cancer Screening
Genetic Screening
• National Cancer Control Programme- Objectives, Schemes.
• NPCDCS

3. • Screening is defined as the identification of
unrecognized disease in an apparently healthy,
asymptomatic population by means of tests,
examinations or other procedures that can be applied
rapidly and easily to the target population.
.
Screening

4. Principlesofscreening
● Disease should be important health problem in terms of frequency and/or severity.
● Natural history of disease presents window of opportunity for early
detection.
● Effective treatment should be available that favorably alters natural history of disease.
● Treatment should be more effective if initiated earlier than during the symptomatic stage.
● Suitable screening test should be available.
● Appropriate screening strategy for the target population (i.e. age to begin and screening
interval)

5. • For cancer screening to be effective, screening tests must meet two criteria.
1. First, the screening test must be able to detect cancer at an earlier stage than if it
was detected as a result of symptom development.
2. Second, evidence must support that treatment given at an earlier stage results
in improved outcomes
Multiple organizations have published screening guidelines
variety of malignancies, both for average-risk and high-risk populations.
In general, consensus exists among screening recommendations for the most common
malignancies, including breast, cervical, colorectal, lung, and prostate cancer.

6. Cancer Screening
• Cancer screening aimsto detect cancer before symptoms
appear.
• This mayinvolve blood tests, urine tests, or medical imaging.
• The benefits of screening in terms of cancer prevention, early
detection and subsequent treatment must be weighed against any
harms.
• Countries often focus their screening recommendations on the
major forms of treatable cancer found in their population.

7. Breast cancer Screening

8. Breast Cancer Risk Stratification
High Risk:
1) women with a prior history of breast cancer;
2) women ≥35 years of age with a 5-year risk of invasive breast cancer ≥1.7% (per
Gail Model);
3) women who have a lifetime risk >20% based on history of lobular carcinoma in
situ (LCIS) or atypical ductal hyperplasia (ADH)/atypical lobular hyperplasia
(ALH);
4) women who have a lifetime risk >20% as defined by models that are largely
dependent on family history;
5) women between the ages 10 and 30 years with prior thoracic RT (eg, mantle
irradiation);
6) women with a pedigree suggestive of or known genetic predisposition.

9. NCCN BREAST SCREENING CONSIDERATIONS-
Average Risk
Screening Women at Average Risk
• For women between ages 25-40 yrs CBE recommended
every 1 to 3 yrs and breast awareness encouraged.
• For women aged >40 yrs Annual CBEand screening
mammography and breast awareness is encouraged.
• Mammograms can often detect a lesion 2 yrs before the
lesion is discovered by CBE. Yearly screening is thought to
be more beneficial.

10. NCCN BREAST SCREENING CONSIDERATIONS- High Risk
• Clinical encounter every 6–12 months.
to begin when identified as being at increased risk but not prior to age 21 y
• Annual screening mammogram.
to begin 10 years prior to the youngest family member with breast cancer but not
prior to age 30 y.
• Recommend annual breast MRI
to begin 10 years prior to youngest family member with breast cancer but not prior
to age 25 y
• Recommend risk reduction strategies
• Breast awareness.

11. CONTD..
Screening Women At Increased Risk
Modified Gail Model assesses the risk of invasive breast
cancer as a function of age, menarche, age at first live birth or
nulliparity, number of first degree relatives with breast cancer,
number of previously benign breast biopsies, atypical
hyperplasia and race.
This model calculates and prints 5-year and lifetime projected
probabilities of developing invasive breast cancer and identifies
increased risk.
Gail model should not be used for women with gene mutation,
strong family history, prior thoracic radiation or for those with
LCIS.

12. CONTD..
For a woman aged 35 yrs or older with a5-yr risk > 1.7%
and patients with LCIS, CBE every 6 to 12 months and
annual mammography along with breast awareness is
encouraged.
For a woman with >20% lifetime risk of breast cancer
(based on family history), breast awareness and beginning
at 30, CBE every 6 to 12 months and annual
mammography. Annual breast MRI is also

13. CONTD..
• For a woman who is a carrier of BRCA 1/2 mutation, CBE every 6-
12 mo starting at age 25, breast awareness, annual mammograms and
breast MRI as an adjunct.

15. MAMMOGRAPHIC SCREENING
A screening mammogram typically involves two x-ray
images of each breast, one craniocaudal and other
mediolateral oblique.
Mammography results are mandated to be reported using
BI-RADS developed by the American College of
Radiology.
BI-RADS – Breast Imaging Reportingand Data System

17. BI-RADS CATEGORIES
Category 0 – Needs additionalImaging
and/or Prior Mammograms to compare
Category 1 –Negative
Category 2 – Benignfindings
Category 3 – Probably Benign; ShortFollow up
Category 4 – Suspicious Abnormality;Biopsy
Category 5 – Highly S/oMalignancy
Category 6 – Known BiopsyProven

18. BREAST MRI SCREENING
The sensitivity of breast MRI at detecting breast cancer is higher than
the sensitivity of mammography, although the specificity of the
former is lower.
NCCN recommends annual MRI as an adjunct in the following
1.Women with known genetic predisposition for HBOC starting at
age 25.
2.Women with prior thoracic radiation between ages 10-30 yrs.
3.Women with >20% lifetime risk as described by ACS guidelines.

19. CERVICALCANCER SCREENING

20. American Cancer SocietyCervicalCancerGuidelines 2020
• Age 21‒24: No screening.
• Age 25‒29: HPV test every 5 years (preferred) HPV/Pap cotest every
5 years (acceptable) Pap test every 3 years (acceptable).
• Age 30‒65: HPV test every 5 years (preferred) HPV/Pap cotest every
5 years (acceptable) Pap test every 3 years (acceptable).
• Age 65 and older: No screening if a series of prior tests were normal.

21. Screening can be discontinued aftertotal hysterectomy for
benign disease.
Screening may be discontinued forwomen with an intact
cervix who are older than 65 yrs with negative previous
results and with no history of abnormal cervical cytology
tests.
Women with co morbid or lifethreatening illness may
discontinue screening.

22. COLO-RECTAL CANCER SCREENING

23. Colon Cancer Risk Stratification
Average Risk:
Age more than 50 years
No history of polyp or adenoma or CRC
No family history of CRC
No history of Inflammatory Bowel disease
High-risk patients :
• (patients with adenomatous polyps,
• history of CRC,
• First degree relative diagnosed with CRC or adenomas.
• inflammatory bowel disease,
• high risk due to family history or genetic testing).

24. The American College of Gastroenterology recommendations
• Colonoscopy screening.
• If single, first-degree relative diagnosed with CRC, or advanced adenoma at age
60+ years, screening every 10 years beginning at age 50 years.
• If single, first-degree relative diagnosed with CRC, or advanced adenoma at age
<60 years or two or more first-degree relatives with CRC or advanced adenoma at
any age, screening beginning at age 40 years or 10 years before the youngest
relative’s diagnosis. Screening should be performed every 5 years.

25. Screening Modalities that detect Adenomatous Polyps and
Cancer
- Colonoscopy every 10 yrs
- Flexible Sigmoidoscopy every 5 yrs
- CT colonography (CTC) every 5 yrs
Screening modalities that primarily detect cancer
- Guaiac-based screening
- Immunochemical based testing annually
-Stool DNA test with high sensitivity ( interval for
screening is uncertain)

26. COLONOSCOPY
A 10 yr interval is appropriate for average risk
patients who had an optimal procedure.
Shorter intervals may be indicated basedon the
quality and completeness of the colonoscopy.
Individual risk factors andphysician
judgment should be included.
Colonoscopy has limitations andcannot detect
all cancers and polyps.

28. FLEXIBLE SIGMOIDOSCOPY
May be performed alone or incombination with
stool based screening.
Requires no sedation unlike colonoscopy and less
bowel preparation, but is limited to examination of
the lower half of the colon tract.
Performed using a scope 60cm orlonger.
Patients with lesions larger than 1cm should directly
be referred for colonoscopy since they are almost
always adenomatous polyps.

30. COMPUTED TOMOGRAPHIC COLONOGRAPHY
Also known as Virtual colonoscopy orCTC.
Advantage of being noninvasive and not requiring sedation.
However , a positive finding requires colonoscopy and extra
colonic findings, which are present, pose a dilemma.
Overall data suggests that CTC may be useful for the
detection of larger polyps however, it is still an evolving
technology.

31. FECAL BASED SCREENINGTESTS
Fecal tests are designed to detect signs of CRC in
stool samples, specifically occult blood or more
recently alterations in exfoliated DNA.
They are noninvasive and no bowel clearance is
necessary.
However, they are less likely to detect
adenomatous polyps.
Sensitivity can be limited by inadequate specimen
collection or suboptimal processing.
These tests are recommended annually alone or in
combination with flexible sigmoidoscopy every 5
years.

32. FECAL OCCULTBLOODTEST
Two FOBT’s are available – Guaiacbased and
Immunochemical.
GuaiacFOBT
-MOA is based on the pseudoperoxidase activity of heme in
blood.
-It is the MC stool test in use for CRC screening.
-Major disadvantage is that it may miss tumors that bleed
in small amounts, intermittently or not at all and high false
positive rate
- It should be performed on three successive

33. FECAL OCCULTBLOODTEST
Fecal ImmunochemicalTest
- Directly detects human globin within Hb.
- Does not require dietary restrictions and single sample is
sufficient.
- It is more sensitive than guaiac FOBT.
Stool DNATest
-Emerging screening tool; detects the presence of known
DNAalterations.
-Not yet been approved by FDA and not considered a first
line screening tool.

34. GENETICSCREENING

35. ASCO GENETIC TESTING GUIDELINES
Personal or family history suggesting genetic cancer susceptibility.
1. The test can be adequately interpreted.
2. The results will aid in the diagnosis or influence the
medical or surgical management of the patient or family
members at hereditary risk of cancer.

36. RECOMMENDATIONS FORHBOC
Considerable initial screening is a reflection of the early age of
onset seen in HBOC.
Women who is a carrier of BRCA 1/2 mutation, training in
breast awareness with regular monthly practice should begin at
age 25.
The woman should have annual mammograms and breast
MRI screening beginning at 25.
Studies show that MRI is more sensitivethan Mammography but
the downside is higher false positive result and higher cost
relative

37. GENETICTESTING

38. GENETICS AND COLORECTALCANCER
Management of individuals with a family history of FAP
depends on whether the familial mutation is known or unknown.
Genetic testing of APC and/or MUTYH is important to differentiate
FAP from MAP and colonic polyposis of unknown etiology.
When a patient with no familial mutation presents with h/o >10
adenomas, then comprehensive genetic testing of APC and/or
MUTYH is recommended.
MUTYH testing can be performed prior to APC testing if a recessive
pattern is apparent in the pedigree.
Genetic counseling and testing is recommended for patients with
multiple adenomatous polyps.

39. LUNGCANCER SCREENING

40. Risk Stratification
• High Risk: Age 55-75 years and more than 30 pack years of smoking /
Age more than 50 years and more than 20 pack years of smoking with
other risk factors.
• Moderate Risk : Age more than 50 years or less than 20 pack years of
smoking.
• Low risk: Age less than 50 years or less than 20 pack years of
smoking.

41. RISK ASSESSMENT
NCCN Screening Panel recommendslung cancer screening using helical LDCT
for individuals with following high risk factors.
1. 55-74 yrs; 30 or more pack year history and if former smoker, have quit within
15 yrs.
Annual screening recommended every 2 yrs.
2.>50 yrs; 20 or more pack year history and additional risk factors.
NCCN Panel does not currently believethat exposure to second hand smoke is an
independent risk factor because the data is weak.

42. NCCN defines moderate risk individuals as those aged
50 yrs or older and with a 20 or more pack-year history
but no additional lung cancer risk factors.
NCCN defines low risk individuals as those younger
than 50 yrs and/or with a smoking history of fewer
than 20 pack-years.
It does not recommend screening for these
individuals.

44. PROSTATE CANCER SCREENING

45. DRE and PSA are the two components usedin Prostate
Screening.
TRUS has been associated with a high false positive
rate, making it unsuitable as a screening tool.
In 2010, ACS recommended that men make an informed
decision about whether to be screened for prostate
cancer.
If screening is done, it should begin at age 50 in men at
average risk who have a life expectancy of at least 10
yrs.

47. ACS advises that if PSA < 2.5ng/ml,retesting may need to be done
only every 2 yrs.
Men with > 2.5ng/ml should have annual testing.
In May 2013, the American Urological Association (AUA) released new
guidelines supporting routine use of PSA in healthy men 55 to 69 yrs
who are at average risk and are asymptomatic.
AUA do not recommend testing in men <40yrs, 40-54 yrs with average
risk, >70 yr old males nor in males with life expectancy less than 10-
15 yrs.

48. Current state of Cancer screening: India

49. Out of 809 women eligible for screening only 6.9% underwent screening
Total n =21015; Eligible women – 4009
Compliance rate: Breast 85%; Cervix 70%; Oral cavity 88%
Screening positivity rate: Breast 3.9%, Cervix 14.9%, Oral cavity 3.9%

50. ICMR in Cancer Screening and Prevention
• HBCR-29.
• PBCR-31.
• The ICMR has taken initiative to publish consensus documents on
common cancers in India to improve quality and standardized cancer
care.
• These are expert and evidence-based guidelines to promote uniformity
and to ensure the quality of treatment across cancer centers in India.
• Establishment of the National Health Mission and insurance schemes
such as Rashtriya Swasthya Bima Yojna, (a central government
initiative); Rajiv Aarogyasri Scheme (an Andhra Pradesh government
initiative); Vajpayee Arogyashree Scheme (a Karnataka government
initiative), and also Gujarat health scheme model

51. Benefits of regular cancer screening
• Getting screened reassures you if the result is normal.
• Cancer screening may help prevent cancer by finding changes in your body that
would become cancer if left untreated.
• Cancer screening helps find cancer early before you have symptoms when it is
easier to treat.
• Cancer screening helps find cancer before it spreads when it is easier to treat.
• Early detection may mean less treatment and less time spent recovering.
• The earlier a cancer is detected, the better your chance of survival.

52. Limitations of regular cancer screening
• Sometimes test results suggest you have cancer even though you don't (called a
false positive).
• The test may not detect cancer even though it is present (called a false negative).
• Some cancers would not necessarily lead to death or decreased quality of life
(overdiagnosis).
• Having screening tests may lead to more tests and procedures that may be
harmful.

53. SUMMARY
• Cancer screening is looking forcancer before a person
has any symptoms.
• False positive and false negative testsare possible.
• Finding the cancer may not improvethe person’s
disease status and stage.
• Finding the cancer may not improvethe person’s
disease status and stage or help Overall Survival.
• Screening studies are done to see whether deaths from
cancer, decrease when people are screened.

55. NCCP
• With the objectives of prevention, early diagnosis and treatment, the
national cancer control programme was launched in 1975.
• In view of the magnitude of the problem and gaps in the
availability of cancer treatment facilities across the country, the
programme was revised in 1984-85 and subsequently in December
2004.

56. Launch: 1975
Primery
prevention
Secondary
prevention
Goals
Tertiary
prevention

57. 1984-85:Amendment
1990-91:District CancerControl (DCC)Prog started
2000-01:Modified D
C
C programme initiated
2004 :Evaluation ofNCCP
2005:Theprogramme wasfurther revised

58. Regional Cancer Centre Scheme-5Cr
Existing regional centres are being further
strengthened to act as referral centres-3Cr

59. Oncology wing development scheme-3Cr
• Started to fill up geographical gaps in the availability of cancer treatment facilities
in the country.
• This scheme had been initiated to fill up the geographic gaps in the availability of
cancer treatment facilities in the country.
• Central assistance is provided for purchase of equipment, which include a cobalt
unit besides other equipment.
• Government hospitals and Government Medical Colleges.

60. District Cancer Control Programme
• Large number of cancer cases can be prevented with suitable health education and early
detection.
• Accordingly, the scheme for district projects regarding prevention, health education, early
detection and pain relief measures was started in 1990-91, has since been revised.

61. Decentralized NGO Scheme
Meant for IEC activities and early detection of cancer.
• The scheme is operated by the nodal agencies and the NGO’s are given financial
assistance for undertaking health education and early detection activities of
cancer.

62. IEC activities at central level
IEC activities at the Central level are to be introduced in order to give wider
publicity about the Anti Tobacco Legislation for discouraging consumption of
cigarettes and other tobacco related products, and creating awareness among
masses about the ill effects of tobacco and tobacco also be given about the rules
being for implementation for various provisions of the anti tobacco
legislation.

63. Tobacco control legislation:
A comprehensive tobacco control legislation titled “the
cigarettes and other Regulation Of Trade and Commerce,
production, supply and distribution) Act, 2003” was passed
by the parliament April, 2003 and notified in Gazette of
India on 25th Feb, 2004.

64. - The important provisions of the Act are:
• Prohibition of smoking in public places
• Prohibition of direct and indirect advertisement of cigarette and other products:
• Prohibition of sale of cigarette and other tobacco products to a person below the
age 18 years
• Prohibition of sale of tobacco products near the educational institutions;
• Mandatory depiction of statutory warnings ( including pictorial warnings) on
tobacco packs.

65. Cancer Atlas:
under the national cancer registry programme, the Indian Council of Medical
Research has developed an Atlas of Cancer in India based in the information
collected for the year 2001-02 from 105 collaborating centres to have an idea of the
pattern of cancer across the country.

66. Research and training:
Training programmes, monitoring and research activities will organized at the
Central under this scheme following training manuals have been developed under the
NCCP for capacity building in cancer control at district level:
- Manual for health professionals
- Manual for cytology
- Manual for palliative care
- Manual for tobacco cessation

67. NPCDCS
National Programme for Prevention and Control of Cancer,
Diabetes, Cardiovascular Diseases and Stroke

68. 1)Prevent and control common NCDs through
behaviour and life style changes,
2)Provide early diagnosis and management
of common NCDs,
3)Build capacity at various levels of health care
forprevention, diagnosis and treatment of
common NCDs,
4)Train human resource within the public
healthsetup i.e doctors, paramedics and nursing
staff to cope with the increasing burden of
NCDs, and
5)Establish and develop capacity for palliative
& rehabilitative care.

69. • Under the National Programme for Prevention and Control of Cancer,
Diabetes, Cardiovascular Disease and Stroke, the GOI has allocated ₹
120 crores each for the establishment of 20 State-level cancer
centers.
• The GOI has also allocated 20 million USD to develop 23 new tertiary
care centers and to strengthen 27 regional cancer centers

70. THANKYOU