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Cancer risk and early detection assessment
Cancer Risk and Early Detection Assessment Linda N. W h i t e and M a r g a r e t R. Spitz
ANCER prevention and early detection, which encompass health education and promotion by defining high-risk groups and identifying individuals who belong to them as well as by controlling morbidity and mortality by early diagnosis and prompt treatment, are together both a target and a process. Initiating the process is the cancer risk assessment, a gathering of personal information to calculate an index of cancer risk. Asking the risk assessment questions begins the second step in assessment: health education, z Once patients understand average risk and the factors that affect that risk, they are empowered to translate prevention knowledge into action by following check-up recommendations, performing selfexaminations, and seeking medical advice promptly when symptoms or signs appear. They can enter a partnership with the professionals to whom they have entrusted their health and assume shareholder status, voting by their actions the course they wish to take. Guidelines for cancer risk assessment have been extensively explored. 1-4 This article discusses risk assessment guidelines and issues in cancer screening. Because half of all cancer cases and more than half of all cancer-related deaths occur in those 65 years and older, 5 special attention is given to physical screening measures in the elderly.
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CANCER RISK ASSESSMENT
The first step in the cancer prevention process is risk characterization. A careful risk assessment serves the multiple purposes of establishing baseFrom the Cancer Prevention and Detection Programs for Nurses, and the Department of Epidemiology, The University of Texas M.D. Anderson Cancer Center, Houston, TX. Linda N. White, RN, MSN: Director, Cancer Prevention and Detection Programs for Nurses, The University of Texas M.D. Anderson Cancer Center. Margaret R. Spitz, MD: Acting Department Chair, the Department of Epidemiology, the University of Texas M.D. Anderson Cancer Center. Address reprint requests to Linda N. White, RN, MSN, Cancer Prevention and Detection, 133, The University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030. Copyright 9 1993 by W.B. Saunders Company 0749-2081/93/0903-001255.00/0
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line data, providing an ideal educational opportunity for evaluating knowledge of risk and for motivating changes in life-style, and enabling the nurse or physician to assess the cancers that pose the greatest risk to the patient, thus allowing the tailoring of a cancer examination and screening program specifically to fit the patient's risk profile. 2 Although the knowledge base of cancer risk factors has been rapidly expanding because of both laboratory and epidemiological studies, researchers and physicians generally agree that apart from age, environmental factors and life-style choices (eg, tobacco, diet, sun exposure) are the major determinants of cancer risk. Theoretically, these are all avoidable exposures. At issue is whether the individual is willing and able to translate cognitive knowledge into risk-reducing behavior.
Basic Elements A detailed personal medical history, a history of life-style exposures, and a family medical history should be obtained from the patient. Personal medical history. The personal medical history should include the usual demographic information yet be a comprehensive picture of the health history. Questions should cover present health status and health care practices, including the schedule of professional screening examinations and self-examinations that the patient follows regularly, l History of exposures in daily living. Patients should be questioned about smoking cigarettes, pipes, or cigars; chewing tobacco or dipping snuff; and being passively exposed to tobacco smoke. Patients should be queried at each visit, and if they smoke, their charts should bear a special identifier. The nurse or physician should assess current smokers' nicotine dependence using the Fagerstrom index6 (Fig 1). Knowledge of the level and duration of smoking and the degree of nicotine dependence will assist the health professional in making informed decisions about the likelihood of successful cessation, the patient's motivation, and whether nicotine replacement therapy would be beneficial. The patient should be queried about diet, occupational exposures to carcinogens (they account Seminars in Oncology Nursing, Vol 9, No 3 (August), 1993: pp 188-197
CANCER RISK AND EARLY DETECTION ASSESSMENT NlcoUne D e p e n d e n c ~
'[89 Test
(~msticm I, How soon afinr you wake u p d o you smoke y o u r
1 Point
2 Polrtts
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Within 30 m i n u t e s
__
No
Yes
__
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T h e first o n e in
t h e first o n e in
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first cigarette? 2. Do y o u find it difficult to refzath f r o m s m o k i n g in places w h e r e it is forbidden, such as t h e l i b r a w , theater, of doctor's office? 3. W h i c h of all t h e cigarettes you smoke in a day is t h e m o s t satisfying?
the morning
Fig 1. These q u e s t i o n s roughly measure dependency on nicotine. Ask the smoker to select the answer to each qusstion that best describes personal smoking habits and to place the score where indicated. A score of less than 7 suggests that the smoker has a low to moderate dependency on nicotine. The closer the score is to 1, the lower the dependency. A score of 7 or more indicates that nicotine dependency is likely and that withdrawal symptoms may occur when the smoker stops smoking. (Adapted with permiSSion,e)
4. How m a n y cigarettes a day do you smoke? 5. Do y o u smoke m o r e d u n n g the m o r n i n g t h a n
1-15
16-25
26 o r mcn~
No
Yes
__
No
Yes
__
d u r i n g t h e rest o f t h e day? 6. DO y o u smoke w h e n you are so i l / t h a t y o u are In b e d most cff the day7 ' 7. Does t h e b r a n d you smoke have a low, medium, or h i g h nicotine c o n t e n t ? rg. How often d o you inhale t h e smoke f r o m y o u r
Low
Medium
High
(~ 0.4 m g )
(0.5-0.9 rag)
(-> 1.0 rag)
Never
Sometin~
Always
cigarette? Total
for 4% to 6% of cancer mortality), alcohol use, exposure to ionizing and ultraviolet radiation, and previous cancers. Emerging as a priority is the need to reduce the intake of fat, especially saturated fat, and to increase the intake of complex carbohydrates and fiber, a diet also consonant with guidelines for preventing coronary artery disease. 7 Family history. A carefully obtained family history of cancer is an integral component of a patient's workup. About 25% of all family histories will yield evidence of cancer in at least one family member. Although 80% to 90% of cancers are considered nongenetic or environmental in origin, it is now recognized that an important interaction occurs between genetic and environmental factors in cancer development. Considerable interindividual variability exists in susceptibility to cancer-causing agents, and only a fraction of individuals exposed to carcinogens develop cancer. For example, not all cigarette smokers will develop lung cancer, and those who do are likely to be genetically susceptible to carcinogens in cigarette smoke. Thus, family history assumes greater importance. The primary family history should include information about the age, health, and vital status of
all first-degree relatives (eg, parents, siblings, offspring). For each cancer diagnosis, age at diagnosis and primary site should be determined for firstdegree relatives to assess the likelihood of any reported cancers occurring by chance. For example, common cancers occurring at common ages (eg, a sibling with breast cancer at age 67 years of age and one with prostate cancer at 79 years of age) may be within the expected number and type for family members at risk. Alternatively, the report of a parent dying of a brain tumor at 26 years of age and a sibling with breast cancer at 32 years of age signals far more unlikely occurrences. The diagnosis of a genetic predisposition to cancer is a signal to evaluate close relatives and to develop long-term management plans that include education, genetic counseling, surveillance, and early intervention.
Health Risk Appraisals The format for gathering this information may be a personal interview, a self-administered questionnaire, or a computer-generated evaluation. No matter how the information is collected, discussion of the findings is imperative. Health risk appraisals traditionally compare an
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individual's health-related behaviors and personal characteristics with mortality statistics and epidemiological data in order to estimate the risk of dying at some future specified time. These instruments rely on self-report, physiological measurements, and computer-assisted calculations; however, the highly quantitative presentation of the data and the risk projections provided may not be completely understood by the clients. Thus, their efficacy is lessened. The accuracy of the arithmetic predictions also has been questioned. Cohen and Stromborg 2 identified instruments available for purchase; however, few focus specifically on cancer risks. Conceptualizing the magnitude of cancer risk factors when their deleterious effects may not be manifest for many years remains difficult,s Although we live in a risk-conscious society, widespread misperceptions of risk exist across a broad spectrum of societal sectors. 9 The public fails to understand the concept of attributable risk and tends to focus instead on industrial and environmental toxic pollutants, which account for 10% or fewer of cancer deaths. 10 People in general appear to be less tolerant of these involuntary exposures than to those readily modified by changes in living
patterns. Some remain reluctant to be informed of their risks and may react with denial, fear, anger, or guilt when faced with their risk. 2 These and all other obstacles to effective communication must be addressed by providing risk information in a clear, concise, nonjudgmental manner. The University of Texas M.D. Anderson Cancer Center has developed CheqUp TM , a health risk assessment instrument specifically designed to address some of these concerns (Fig 2). CheqUp TM is a self-administered questionnaire that elicits demographics, life-style characteristics, family medical history, health practices, and screening status relevant to cancer and cardiovascular disease. The questionnaire is designed for use with an optical scanning device for error-free batch processing. CheqUp TM uses algorithmic logic based on empirical epidemiological data to program individualized feedback to clients. Quantitative feedback about risk, age, life expectancy, or risk of death is not provided. A computer program generates laserprinted individualized letters to clients. The information in the letter is confidential, rapidly responsive, and easily understood, although it may require further elucidation and interpretation in an individual session with a nurse educator. It identi-
36. How often do you eat chicken or other poultry with skin? Sometimes 37. How often do you eat the fat on meat? ~eldom/new Sometimes 3ften/alwa~ 38. What type of fat do you usually use in cooking and/or at the table? Margarine
m Vegetable oil Lard (animal fat, bacon drippings) ILI[O]InMI~IKOv]~l
39. How often do you eat whole wheat bread, high-fiber cereals, or dried beans and peas? Seldom Daily
Fig 2, CheqUp" (Cancer and Health Evaluation Questionnaire-User Profile) uses 67 questions (4 are presented hero) in a Scantron format to profile a patient's cancer and cardiovascular disease risks (Adapted w i t h permission. ~ )
CANCER RISK AND EARLY DETECTIONASSESSMENT
ties and explains site-specific risks for cancer and characterizes cardiovascular risk status. The letter specifically emphasizes actions to be taken and reinforces healthful life-style practices. Cancer screening recommendations are based on the risk data and family history information provided by the respondent. In introductory paragraphs, the letter thanks the patient for returning the CheqUp TM questionnaire and in a friendly tone comments on basic aspects that affect health such as smoking habits ("As a smoker, you probably know the many reasons you should quit"), weight, and diet ("From the information you have given us, it appears that you are eating a sensible low-fat diet"). The letter is then divided into fewer than 10 brief sections (eg, Heart Disease, Breast Cancer, Diet Tips) that briefly discuss incidence, symptoms, risks, and screening recommendations and specifically relate that information to the patient's questionnaire responses ("Your last Pap test was within the past 2 years. Continue to have regular Pap smears on the schedule that your physician indicates is appropriate for you"). The two- or three-page letter closes with the recommendation that patients discuss it with their physicians during their next examination. PHYSICAL ASSESSMENT BY SITE
The basics of the physical examination have been described in detail elsewhere. 1.3.4 This article highlights issues in the screening examinations for skin and head and neck cancer, breast cancer, male genitourinary cancer, gynecologic cancer, colorectal cancer, and lung cancer. Suggestions for incorporating early detection methods into clinical practice follow. Skin and Head and Neck Cancer
Skin cancer is the most common cancer, and its incidence continues to rise. 11 The elderly, who have been exposed the longest to solar rays, are at greatest risk, and 40% to 50% of those who live to be 65 years old will have at least one skin cancer. Persons at high risk should be encouraged to have a professional examination once a year, and they should be taught how to perform a skin selfexamination. 1,4 After appropriate training, nurses can incorporate skin cancer assessment and examination into everyday clinical practice. The skin assessment should not be postponed until a peri-
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odic physical examination because many seek medical attention only when ill. The increase in melanoma increases the importance of skin assessment, especially for those living in the Sun Belt. Nurses who perform head and neck screenings should review the patient's file or question the patient to find any evidence of factors increasing head and neck cancer risk (eg, tobacco use, poor oral hygiene, or high consumption of salted fish). Reviewing symptomatology (Does the patient have unilateral nasal obstruction or discharge, dysphagia, hoarseness, cervical adenopathy, or skin ulcerations?) and systematically performing a physical examination (inspection and palpation) of the head and neck are fundamental to early detection. 12 Breast Cancer
In 1992, the National Cancer Institute (NCI) revised the lifetime probability of an American woman developing breast cancer to one in eight, 13 heightening screening's importance. Optimal screening for breast cancer includes the triad of clinical examination, mammography, and breast self-examination (BSE) as routine health practice. The physical examination, performed by a nurse or physician, includes inspection, palpation, and a check for and evaluation of nipple discharge. Physical examination permits the discovery of cancers that appear in the intervals between regular screening or those cancers not detectable by mammography (masses in dense breasts of young women). 14 The quality and effectiveness of clinical breast examination for women of all ages must be improved, especially if the nurse or physician is to teach BSE. 15 Although techniques vary, nothing substitutes for a thorough 2- to 5-minute examination of the woman sitting upright with arms elevated and lying supine. 14'16 Mammography has unequivocal support as a screening procedure in women more than 50 years of age and has been shown to be beneficial in women younger than 50 years of age. Women over 50 years of age who had a screening mammogram and a physical breast examination between 40 and 49 years of age showed a 30% reduction in breast cancer mortality as compared with an unscreened group. 17 Women 40 to 49 years of age who were regularly screened had a significant reduction in breast cancer mortality.4'18 Underscoring their belief in screening in this group, the NCI, the Amer-
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ican Cancer Society (ACS), the American College of Radiology, and nine other professional medical organizations recommend that women 40 to 49 years of age have a mammogram every 1 to 2 years) 9 These same organizations also recommend annual mammography for women 50 years of age and older. Breast self-examination (BSE), although not technically a method for detecting cancer in its earliest stages, is recognized as an adjunctive technique for cancer detection, and practicing BSE does have advantages. 2~ In one study, women who practiced BSE sought medical care more rapidly and were diagnosed at an earlier stage of disease than women who did not, and after 5 years there was a significant difference (p < .0001) between the survival rates of self-examiners and non-selfexaminers. 21 This work confirmed earlier findings. 22 One-on-one personal instruction is necessary for women to become regular self-examiners, z3 One study found that having confidence in the ability to perform BSE correctly also increased the likelihood of practicing it. Not associated with confidence was simply reading about BSE. Maternal history of breast disease, living with a sexual partner, and lacking fear that breast loss would compromise attractiveness also positively affected BSE practice. 23 Champion 2~ reported that addressing attitudes and beliefs that pose barriers to practicing BSE can significantly improve BSE proficiency and frequency. 2~Champion, along with Foster and colleagues, 15 has called for intensifying efforts to improve proficiency in BSE and clinical breast examination. Most women do not practice BSE, and in one study only 26% of nurses were found to regularly practice BSE, although 68% believed BSE had definite value. 24 Nurses, who are a "lifeline" to patients with cancer, 25 can be no less to asymptomatic patients who are uninformed about how to reduce breast cancer risk and how to detect it. Nurses who want to encourage regular BSE in their patients should practice BSE personally and teach it individually, stress regularity in practice (eg, making notes in a journal, keeping a record, or reinforcing practice with a reward), emphasize the importance of prompt medical advice after an irregularity is detected (teach women about stagedependent prognosis), and reinforce the benefits of having a physician who supports BSE. Simplifying
BSE technique, emphasizing family in motivating performance, and individualizing instruction and technique are just three of several ways that have been suggested to improve outreach. 14.2o Male Genitourinary Cancer
Prostate and testicular cancer represent over one fifth of all cancer cases in men. Prostate cancer occurs most frequently in men 50 years of age and older, whereas testicular cancer, which accounts for about 1% of cancer cases in men, most commonly occurs in the young (15 to 40 years of age). Prostate cancer is twice as common in blacks as in whites. Because prostate cancer occurs most commonly in older men, its symptoms may be mistakenly attributed to aging. These symptoms include nonspecific urinary symptoms--frequency, dysuria, complete urinary retention, and hematuria. Often symptoms are indicative of late complications .4 The digital rectal exam (DRE), measure of prosrate-specific antigen (PSA), and transrectal ultrasonography are the three methods used to screen for prostate cancer. The Prostate Cancer Detection Clinic at The University of Texas M.D. Anderson Cancer Center uses all three, and the Cancer Prevention and Detection Programs for Nurses teaches nurses complete male genitourinary assessment through its comprehensive training programs. In the DRE, the prostate is palpated transrectally to detect changes in size, shape, contour, consistency, and borders. 26 Specific steps in the DRE are outlined elsewhere. 1,z7 PSA, which is more sensitive than specific, helps monitor disease and is currently being investigated as a screening method, along with transrectal ultrasonography and DRE, in the multicenter American Cancer Society National Prostate Cancer Detection Project trial. 28 Evidence continues to mount indicating that family history may be a risk factor for prostate cancer. Practical application of this knowledge to screening involves combining the detection methods in men with familial patterns. Reports indicate that risk may be doubled for men whose father or brother has a history of prostate cancer. In these men, DRE, serum PSA assays, and transrectal ultrasonography might be used for screening. 29 The nurse or physician can be especially valuable in teaching men 40 years of age and older the importance of regular professional examinations.
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Counseling improves compliance by increasing knowledge and dispelling myths. 29 Men who have a family history of prostate cancer need regular yearly examinations and should request them if not recommended by their physician. Elderly men who are especially at risk--80% of cases occur in men 65 years of age or olderl'29--may be geographically isolated or infirm and need special programs, such as a mobile screening effort, to obtain regular screening. Cohen and Frank-Stromborg2 advised that when elderly men are hospitalized, neither nurse nor physician should be deterred by a chart that reads "rectal exam deferred" and should determine whether the patient has had an exam within the last year. Furthermore, any professional who is unable or too embarrassed to perform a DRE should secure someone to perform the examination. Nurses who wish to develop skills in male genitourinary screening examinations can be trained at workshops or by participating in the ACS prostate screening project. Although rare, testicular cancer is the most common cancer in males 15 to 40 years of age. Typically these young men postpone seeking treatment about 6 months, thereby losing the advantage of earlier detection and prompt treatment. Young men appear to know little of the indications of the disease but have demonstrated an ability to respond to instruction. 3~ They need to know that unilateral enlargement of the testicles, the appearance of nodules or lumps, or changes in testicular consistency are conditions needing prompt medical attention. The ACS recommends that men have a professional testicular assessment annually and that they perform testicular self-examination (TSE) monthly beginning in puberty, l~ Nurses or physicians may estimate the weight and equality of size of each testis by holding a testis in each hand, lifting them, and then pulling them forward gently in the scrotal sac. Palpation of the testes, epididymis, and vas deferens is performed to detect any abnormalitiesY No prospective randomized trial of TSE has confirmed its effectiveness in detecting cancer early, and the US Preventive Services Task Force (USPSTF) found insufficient evidence to recommend TSE. 31 Nonetheless, recognizing that the USPSTF recommendations addressed the quality of existing scientific evidence more than standards of care, the NCI still recommends TSE. ~1
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Gynecologic Cancer Nurses who become proficient in performing pelvic examinations are an asset to nursing, to the community, and to a physician's practice. Patients are pleased and satisfied with examinations performed by nurses, and the examinations are also more cost effective. Nurses can reach the inadequately served population who may be at highest risk, including older women or poor women. Nurse colposcopists expand the outreach capability even more. Cervical cancer detection has been compromised by controversy over effective use of the Papanicolaou (Pap) smear to identify cervical cancer and its precursors. Controversial failings of current screening include patient error (eg, failure to have follow-up examinations, delay in seeking medical attention), physician error (failure to do pelvic examination with Pap test or to act on abnormal cytological findings), and laboratory error (smears inaccurately read). 32 Reducing the proportion of false-negative smears and increasing uniformity in reporting cervical smears are goals of the Bethesda reporting system, quality control measures imposed by Congress on cytology laboratories, and quality control monitoring by automated cytological preparation scanning devices. 33,34
To restore faith in the workability and validity of screening and to ensure the accessibility of testing to as many women as possible, Cohen and FrankStromborg2 recommended that nurses educate all women about the early symptoms of gynecologic cancer and the need to seek advice, as well as about recommendations for Pap smear screening. Women with a history of abnormal or questionable findings should be encouraged to call rather than rely on being called about Pap findings. Whenever results are abnormal or questionable, women should be counseled about having regular followup examinations and receiving additional medical care if needed. Older women should be taught to ask for a Pap smear when they have a physical examination. To help reduce laboratory error, physicians and nurses need to perfect their smeartaking skills. 1,35,36 Laboratory reliability, perhaps now enhanced by quality control measures, can maintain or further improve reliability by restricting the workload, improving training, and nurturing cooperative communication between the pathologist and the smear provider. 32 Nurses should
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strive to inform young women about having Pap smears as soon as they become sexually active. 4 Health professionals caring for older women in retirement centers, extended care facilities, or other settings should educate them about signs and symptoms of gynecologic cancers and stress the importance of having gynecologic exams after menopause. Older women need to know that certain premalignant conditions place them at higher risk for certain gynecologic cancers. 4 Women taking estrogen need to be routinely monitored for early detection of endometrial cancer, s Health professionals also should be aware of physical changes in older women that make pelvic examinations and Pap smears uncomfortable. Decreased mobility of the femoropelvic structure and narrowing of the vaginal orifice may make examinations more painful. The left lateral Sims' position instead of the lithotomy position has been used to ease the discomfort caused by lack of mobility.
Colorectal Cancer Colorectal cancer is a leading cause of death in men and women older than 35 years of age and the second most common cancer in the United States.1 ~ Screening recommendations are based on age and both personal and family history. The recommendations of the ACS, the American Gastroenterological Association, the NCI, the American College of Physicians, and the World Health Organization Collaborating Center for Prevention of Colorectal Cancer are similar, requiring annual fecal occult blood testing and flexible sigmoidoscopy every 3 to 5 years beginning at 50 years of age. s7 The ACS also recommends an annual DRE every year after 40 years of age. The feasibility of periodic colonoscopy or barium enema for those over 60 years of age requires study. Controversy exists over fecal occult blood screening because of questions of effectiveness, high false-positive rates, and high cost of followup testing, and poor compliance. Analyses currently under way of large-scale fecal occult blood screening studies should yield information about mortality reduction. New screening tests are needed and are being developed, including immunochemical tests that detect bleeding and other changes caused by cancer. 4'37 In the future, more specific and sensitive molecular techniques may detect abnormal genetic elements in stool or b l o o d y Recent work supports the value of screen-
ing sigmoidoscopy. In one study, those screened had a 60% to 70% lower risk of death from rectal or distal colon cancer than those not screened. 38 In a retrospective case-control review, researchers concluded that screening sigmoidoscopy could substantially reduce mortality from rectal and distal colon cancers. 39 Health professionals who correct misconceptions about colorectal cancer and Americans' knowledge about it perform an important service. Advising people about colorectal cancer's common occurrence yet reassuring them that this cancer does not necessarily result in a permanent colostomy helps change their concept of the disease. Health professionals can also encourage more healthful eating habits by advising patients to avoid obesity; to decrease total fat intake to about 30% of total calories; to eat more high-fiber foods, foods high in vitamins A and C, and cruciferous vegetables; and to consume alcoholic beverages and salt-cured, smoked, and nitrite-cured foods in moderate or lower amounts. 4'7
Lung Cancer Cigarette smoking is the largest preventable cause of premature death and disability and the major single cause of cancer mortality. In 1988, Texas statistics indicated that of the total $4.3 billion cost of cancer for that year, 25% could be attributed to lung cancer exclusively.4~ Smoking, an expensive, debilitating, and time-consuming habit six to eight times as addicting as alcohol, 41 is responsible for 87% of lung cancer deaths and 30% of all cancer deaths.S'11 Because lung cancer gives no early clues and most symptoms are those of advanced disease, primary prevention offers the best hope of combating this cancer. Most smokers begin smoking in adolescence; thus, preventive efforts should begin early. Smoke-free policies in businesses and public places restrict time available for smoking and increase social pressure on the smoker to quit. Multiple approaches appear to work best in trying to get someone to stop smoking: recommendations from both physicians and nonphysicians, recommendations on multiple occasions, individualized and direct face-to-face advice, materials that are educationally and culturally relevant, referral to cessation programs, scheduled reinforcement, and drug therapy. 4 Having available reminders of why quitting is beneficial may help quitters persevere in
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their resolution to stop (Table 1). The decrease in physicians who smoke, from approximately 50% in the 1950s to less than 20% in the 1980s, has had a profound effect on patients' smoking practices, is Although among nurses, smoking is declining and cessation rates are increasing, nurses have failed to reduce smoking in their professional ranks as dramatically as other health professionals and have been reprimanded for the lost opportunity to set a good example. 18.25,43 INCORPORATING EARLY DETECTION INTO CLINICAL PRACTICE
Every physician's office and every clinic examining room can become a cancer screening center Table 1. The Benefits of Quitting Smoking
The same great benefits go to all quitters, and they start right away. Soon after your last cigarette, your body starts to heal itself. Look at these benefits: After 20 Minutes Your pulse, blood pressure, and body temperature return to normal as nicotine is filtered out of your body. After 12 Hours The carbon monoxide level in your blood returns to normal. After 24 Hours Your circulation and fine motor coordination improve. After 6 Weeks Your smoker's cough begins to disappear. After 3 Months Your senses of smell and taste improve; stamina and endurance increase; immune system improves. After 1 Year Your risk of coronary heart disease is half what it was when you were a smoker. After 5 Years Your risk of cancers of the mouth, throat, and esophagus decreases by half. After 5-15 Years Your risk of stroke becomes the same as that of peop|e who've never smoked. After 10-15 Years Your risks of premature death, lung cancer, bladder cancer, and peripheral artery disease go down significantly. Your risk of coronary heart disease is as low as that of someone who's never smoked at all. Adapted with permission from Break Clear TM, the smoking cessation component of Life Cheq TM Cancer Prevention Program, Division of Prevention. The University of Texas M.D, Anderson Cancer Center (713) 792-3011.42
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without reorganizing office or clinic procedure, without hiring new personnel, and without major investments of time or money. The task of reducing the morbidity and mortality of cancer and enhancing health in a population of patients begins with a commitment to a goal, planning, and restructuring the project into manageable tasks. Pommerenke and Smart44 urged the implementation of early cancer detection efforts by primary care practitioners and named ways of modifying practice to save lives through prevention. Physicians and nurses can engage patients in a health partnership aimed at controlling cancer by reducing cancer risk and improving early detection. This effort expands beyond the office walls as the patient incorporates changes in life-style to reduce risk and perhaps influences others to do the same,
The risk assessment can be incorporated into the medical history review by making the risk questions part of the history questionnaire or by evaluating cancer risks separately. Answers are usually written on a form by the patient or obtained during an interview by the nurse. Discussion with the patient of risk-related behaviors, such as smoking or diet, is important, but following through with screening procedures and recommendations is also critical. Why compile a risk profile and fail to review and interpret the assessment or fail to include cancer detection techniques in the physical examination? Why perform a Pap smear and fail to follow up with more frequent screenings for those needing them? Nurses should consider these specific suggestions: (1) discuss risk reduction during a review of assessment, when scheduling the follow-up visit, or before or after the examination; (2) encourage patients to observe regular screening guidelines to practice self-examination and to expand what they have learned; (3) supply written materials supporting the message so that patients who are shy, uncomfortable, or nervous during an office visit can review the material in the privacy of their home; and (4) use color-coded file stickers or program the computer system as reminders of which patients need to schedule follow-up visits. Some offices complete follow-up reminder cards at the time of the visit for later mailing. Elderly patients need care beyond the support that is offered to the typical asymptomatic patient. Elders need nurses to be advocates to learn about their socioeconomic concerns, to listen actively
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and encourage meaningful conversation, to understand their fear of cancer, and to respect their more private and more reticent ways. An elderly woman who claims she just wants a "check for cancer" may have symptoms or signs of disease that she will not divulge unless she is encouraged and made to feel secure. Elder advocates can hold clinics in nursing homes, senior centers, geriatric day-care centers, and retirement homes where large populations of the elderly live. 5 Oncology nurses are role models and leaders in cancer control efforts. Because health professionals have been trained to address the diagnostic and therapeutic expectations of patients, they are often unsure of how to proceed with risk assessment and intensive interventions. They are familiar with the basic risk factors but lack understanding of the interactions of these factors and exact risk magnitudes. Researchers surveyed members of the American Society of Clinical Oncology and concluded that oncologists were " a major untapped potential resource for implementation of CPC (cancer prevention and control) objectives." The researchers determined that if oncologists incorporated cancer prevention and detection education into their own practices, it would increase prevention and detection in the practices of other health professionals because the oncologists were perceived as leaders in their field. 45 No less could be said of oncology nurses. One of the barriers perceived by these oncologists was that they lacked patients without cancer. Admittedly, discussing cancer prevention with pa-
tients who already suffer from a diagnosed neoplasm is a delicate issue, but the existent cancer does not nullify the nurse's responsibility to assess other existing or potential health problems and to intervene. Patients with cancer who face increased risk for other cancers must first be allowed to meet the emotional and physical challenges of existing disease before being counseled about other cancers and changes in life-style. Incorporating early detection tests into the patient's workup and discussing the test results at a time when the patient has the reserve for health promotion is advisable. SUMMARY
Nurses and physicians form an ideal corps for implementing cancer prevention and early detection efforts: providing health education, promoting health enrichment, defining high-risk groups and identifying patients who belong to them, and providing screening to ensure early diagnosis and prompt treatment. A personal medical history, a history of exposures in life-style, and a family history form the foundation for cancer risk assessment. The physical examination that follows takes into account the incidence and indications of cancer at various sites and the patient's risk profile. Health professionals can incorporate screening techniques into everyday practice by gathering information in the medical history, incorporating cancer detection in the physical examination, following up with more frequent screenings or referrals for those needing them, and becoming cancer detection advocates among patients and professional peers.
REFERENCES 1. The University of Texas M.D. Anderson Cancer Center Cancer Prevention and Detection Programs Staff: Cancer Prevention and Detection in the Cancer Screening Clinic. Houston, TX, The University of Texas M.D. Anderson Cancer Center, 1988 2. Cohen RF, Frank-Stromborg M: Cancer risk and assessment, in Groenwald SL, Frogge MH, Goodman M, Yarbro CH (eds): Cancer Nursing: Principles and Practice (ed 2). Boston, MA, Jones and Bartlett, 1990, pp 103-118 3. White LN: Cancer risk assessment. Semin Oncol Nurs 2:184-190, 1986 4. Frank-Stromborg M, Cohen R: Assessment and interventions for cancer prevention and detection, in Groenwald SL, Frogge MH, Goodman M, Yarbro CH (eds): Cancer Nursing: Principles and Practice (ed 2). Boston, MA, Jones and Bartlett, 1990, pp 119-160 5. Frank-Stromborg M: The role of the nurse in early detec-
tion of cancer: Population sixty-six years of age and older. Oncol Nurs Forum 13:66-74, 1986 6. Fagerstrom KO, Schneider NG: Measuring nicotine dependence: A review of the Fagerstrom tolerance questionnaire. J Behav Med 12:159-182, 1989 7. Tompkins ME: Decreasing cancer risks through nutrition education. Dimens Oncol Nurs 4:5-11, 1990 8. Newell GR, Vogel VG: Personal risk factors: What do they mean? Cancer 62:1695-1701, 1988 9. Upton AC: The biological effects of low-level ionizing radiation. Sci Am 246:41-49, 1982 10. Doll R, Peto R: The causes of cancer. J Natl Cancer Inst 66:1191-1308, 1981 11. American Cancer Society: Cancer Facts and Figures, 1992. Atlanta, GA, ACS, 1992 12. Schleper JR: Prevention, detection, and diagnosis of head and neck cancers. Semin Oncol Nurs 5:139-149, 1989 13. National Cancer Institute, Office of Cancer Communi-
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cations: Lifetime Probability of Breast Cancer in American Women. Cancer Information Service Cancer Facts Series. Betbesda, MD, NCI, 1992 14. McKenna RJ, Greene P, Winchester DP, et al: Breast self-examination and breast physical examination. Cancer 69: 2003-2004, 1992 (suppl) 15. Foster RS Jr, Worden JK, Costanza MC, et al: Clinical breast examination and breast self-examination. Cancer 69: 1992-1998, 1992 (suppl) 16. Winchester DP: Physical examination of the breast. Cancer 69:1947-1949, 1992 (suppl) 17. Dodd G: Screening for the early detection of breast cancer. Cancer 62:1781-1783, 1988 18. Fink DJ: Preventive strategies for cancer in women. Cancer 60:1934-1941, 1987 19. Dodd G: American Cancer Society guidelines on screening for breast cancer: An overview. Cancer 69:1885-1887, 1992 (suppl) 20. Champion V: The role of breast self-examination in breast cancer screening. Cancer 69:1985-1991, 1992 (suppl) 21. Huguley C, Brown R, Greenberg R, et al: Breast selfexamination and survival from breast cancer. Cancer 62:13891396, 1988 22. Foster RS Jr, Costanza MD: Breast self-examination practices and breast cancer survival. Cancer 53:999-1005, 1984 23. Bennett S, Lawrence R, Fleischmarm K, et al: Profile of women practicing breast self-examination. JAMA 249:488491, 1983 24. Heyman E, Tyner R, Phipps C, et al: Is the hospital setting the place for teaching breast self-examination? Cancer Nurs 14:35-40, 1991 25. Brody J: Cancer education: How nurses can help. Oncol Nuts Forum 13:18-20, 1986 26. Willson PC: Prostate cancer II: The nurse's role in screening and early diagnosis for primary disease and recurfence. Nut's Intervent Oncol 4:4-5, 1992 27. Willson P: Testicular, prostate and penile cancers in primary care settings: The importance of early detection. Nurse Pratt 16:18-26, 1991 28. Kane RA, Littrup PJ, Babaian R, et al: Prostate-specific antigen levels in 1695 men without evidence of prostate cancer: Findings of the American Cancer Society National Prostate Cancer Detection Project. Cancer 69:1201-1207, 1992 29. Spitz MR: Prostate cancer: Risk factor update. Cancer Bull 44:61-63, 1992 30. Rudolf VM, Quinn KLM: The practice of TSE among college men: Effectiveness of an education program. Oncol Nurs Forum 15:45-48, 1988 31. Smart CR: Critique of the Early Cancer Detection
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Guidelines of the U.S. Preventive Services Task Force and of the National Cancer Institute. Mayo Clin Proc 65:892-898, 1990 (editorial) 32. Koss LG: The Papanicolaou test for cervical cancer detection: A triumph and a tragedy. JAMA 261:737-743, 1989 33. Koss LG: The Betbesda system of reporting pap smears. Prim Care Cancer 12:24, 1992 34. Koss LG: The cervical smear (Pap smear): New directions, in Gynecologic Pathology. Final Program and Abstracts of the Thirty-first Annual Conference of the Houston Society of Clinical Pathologists. Houston, TX, The University of Texas M.D. Anderson Cancer Center, 1991, pp 22 35. Chin HG: The Pap smear: Suggestions to help you reduce the false-negative rate in your practice. Prim Care Cancer 12:11-21, 1992 36. Ferenczy A: The Pap test: Why, how, and when to take it [videocassette]. Angou, Quebec, Canada, BioVision, 1991 37. Levin B: Screening sigmoidoscopy for colorectal cancer. N Engl J Med 326:700-701, 1992 (editorial) 38. Selby JV, Friedman GD, Quesenberry CP Jr, et al: A case-control study of screening sigmoidoscopy and mortality from colorectal cancer. N Engl J Med 326:653-657, 1992 39. Newcomb PA, Norfleet RG, Storer BE, et al: Screening sigmoidoscopy and colorectal cancer mortality. J Natl Cancer Inst 84:1572-1575, 1992 40. The Texas Cancer Council, the Texas Department of Health, the University of Texas M.D. Anderson Cancer Center, et al: Impact of Cancer on Texas. Houston, TX, The University of Texas M.D. Anderson Cancer Center, 1991 41. LeMalstre CA: Reflections on disease prevention. Cancer 62:1673-1675, 1988 42. Kondo A, Eriksen M: Break Clear, the Smoking Cessation Component of Life Cbeq Cancer Prevention Program. Houston TX, The University of Texas M.D. Anderson Cancer Center, 1991 43. Gritz ER, Berman BA, Marcus AC, et al: Ethnic variations in the prevalence of smoking among registered nurses. Cancer Nuts 12:16-20, 1989 44. Pommerenke FA, Smart CR: Early detection of cancer in the primary care physician's practice: Guidelines are not enough. Cancer Bull 44:11-16, 1992 45. Chlebowski RT, Sayre J, Stomberg M, et al: Current attitudes, practice, and perceived barriers of clinical oncologists to cancer prevention and control. Proc Am Soc Clin Oncol 8: A234, 1989 (abstract) 46. The Department of Epidemiology, University of Texas M.D. Anderson Cancer Center: Cheq Up: A Lifestyle Guide for the 90s. Houston, TX, University of Texas M.D. Anderson Cancer Center, 1992
ANCER prevention and early detection, which encompass health education and promotion by defining high-risk groups and identifying individuals who belong to them as well as by controlling morbidity and mortality by early diagnosis and prompt treatment, are together both a target and a process. Initiating the process is the cancer risk assessment, a gathering of personal information to calculate an index of cancer risk. Asking the risk assessment questions begins the second step in assessment: health education, z Once patients understand average risk and the factors that affect that risk, they are empowered to translate prevention knowledge into action by following check-up recommendations, performing selfexaminations, and seeking medical advice promptly when symptoms or signs appear. They can enter a partnership with the professionals to whom they have entrusted their health and assume shareholder status, voting by their actions the course they wish to take. Guidelines for cancer risk assessment have been extensively explored. 1-4 This article discusses risk assessment guidelines and issues in cancer screening. Because half of all cancer cases and more than half of all cancer-related deaths occur in those 65 years and older, 5 special attention is given to physical screening measures in the elderly.
C
CANCER RISK ASSESSMENT
The first step in the cancer prevention process is risk characterization. A careful risk assessment serves the multiple purposes of establishing baseFrom the Cancer Prevention and Detection Programs for Nurses, and the Department of Epidemiology, The University of Texas M.D. Anderson Cancer Center, Houston, TX. Linda N. White, RN, MSN: Director, Cancer Prevention and Detection Programs for Nurses, The University of Texas M.D. Anderson Cancer Center. Margaret R. Spitz, MD: Acting Department Chair, the Department of Epidemiology, the University of Texas M.D. Anderson Cancer Center. Address reprint requests to Linda N. White, RN, MSN, Cancer Prevention and Detection, 133, The University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030. Copyright 9 1993 by W.B. Saunders Company 0749-2081/93/0903-001255.00/0
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line data, providing an ideal educational opportunity for evaluating knowledge of risk and for motivating changes in life-style, and enabling the nurse or physician to assess the cancers that pose the greatest risk to the patient, thus allowing the tailoring of a cancer examination and screening program specifically to fit the patient's risk profile. 2 Although the knowledge base of cancer risk factors has been rapidly expanding because of both laboratory and epidemiological studies, researchers and physicians generally agree that apart from age, environmental factors and life-style choices (eg, tobacco, diet, sun exposure) are the major determinants of cancer risk. Theoretically, these are all avoidable exposures. At issue is whether the individual is willing and able to translate cognitive knowledge into risk-reducing behavior.
Basic Elements A detailed personal medical history, a history of life-style exposures, and a family medical history should be obtained from the patient. Personal medical history. The personal medical history should include the usual demographic information yet be a comprehensive picture of the health history. Questions should cover present health status and health care practices, including the schedule of professional screening examinations and self-examinations that the patient follows regularly, l History of exposures in daily living. Patients should be questioned about smoking cigarettes, pipes, or cigars; chewing tobacco or dipping snuff; and being passively exposed to tobacco smoke. Patients should be queried at each visit, and if they smoke, their charts should bear a special identifier. The nurse or physician should assess current smokers' nicotine dependence using the Fagerstrom index6 (Fig 1). Knowledge of the level and duration of smoking and the degree of nicotine dependence will assist the health professional in making informed decisions about the likelihood of successful cessation, the patient's motivation, and whether nicotine replacement therapy would be beneficial. The patient should be queried about diet, occupational exposures to carcinogens (they account Seminars in Oncology Nursing, Vol 9, No 3 (August), 1993: pp 188-197
CANCER RISK AND EARLY DETECTION ASSESSMENT NlcoUne D e p e n d e n c ~
'[89 Test
(~msticm I, How soon afinr you wake u p d o you smoke y o u r
1 Point
2 Polrtts
3 Points
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Within 30 m i n u t e s
__
No
Yes
__
Any other than
T h e first o n e in
t h e first o n e in
the morning
Score
first cigarette? 2. Do y o u find it difficult to refzath f r o m s m o k i n g in places w h e r e it is forbidden, such as t h e l i b r a w , theater, of doctor's office? 3. W h i c h of all t h e cigarettes you smoke in a day is t h e m o s t satisfying?
the morning
Fig 1. These q u e s t i o n s roughly measure dependency on nicotine. Ask the smoker to select the answer to each qusstion that best describes personal smoking habits and to place the score where indicated. A score of less than 7 suggests that the smoker has a low to moderate dependency on nicotine. The closer the score is to 1, the lower the dependency. A score of 7 or more indicates that nicotine dependency is likely and that withdrawal symptoms may occur when the smoker stops smoking. (Adapted with permiSSion,e)
4. How m a n y cigarettes a day do you smoke? 5. Do y o u smoke m o r e d u n n g the m o r n i n g t h a n
1-15
16-25
26 o r mcn~
No
Yes
__
No
Yes
__
d u r i n g t h e rest o f t h e day? 6. DO y o u smoke w h e n you are so i l / t h a t y o u are In b e d most cff the day7 ' 7. Does t h e b r a n d you smoke have a low, medium, or h i g h nicotine c o n t e n t ? rg. How often d o you inhale t h e smoke f r o m y o u r
Low
Medium
High
(~ 0.4 m g )
(0.5-0.9 rag)
(-> 1.0 rag)
Never
Sometin~
Always
cigarette? Total
for 4% to 6% of cancer mortality), alcohol use, exposure to ionizing and ultraviolet radiation, and previous cancers. Emerging as a priority is the need to reduce the intake of fat, especially saturated fat, and to increase the intake of complex carbohydrates and fiber, a diet also consonant with guidelines for preventing coronary artery disease. 7 Family history. A carefully obtained family history of cancer is an integral component of a patient's workup. About 25% of all family histories will yield evidence of cancer in at least one family member. Although 80% to 90% of cancers are considered nongenetic or environmental in origin, it is now recognized that an important interaction occurs between genetic and environmental factors in cancer development. Considerable interindividual variability exists in susceptibility to cancer-causing agents, and only a fraction of individuals exposed to carcinogens develop cancer. For example, not all cigarette smokers will develop lung cancer, and those who do are likely to be genetically susceptible to carcinogens in cigarette smoke. Thus, family history assumes greater importance. The primary family history should include information about the age, health, and vital status of
all first-degree relatives (eg, parents, siblings, offspring). For each cancer diagnosis, age at diagnosis and primary site should be determined for firstdegree relatives to assess the likelihood of any reported cancers occurring by chance. For example, common cancers occurring at common ages (eg, a sibling with breast cancer at age 67 years of age and one with prostate cancer at 79 years of age) may be within the expected number and type for family members at risk. Alternatively, the report of a parent dying of a brain tumor at 26 years of age and a sibling with breast cancer at 32 years of age signals far more unlikely occurrences. The diagnosis of a genetic predisposition to cancer is a signal to evaluate close relatives and to develop long-term management plans that include education, genetic counseling, surveillance, and early intervention.
Health Risk Appraisals The format for gathering this information may be a personal interview, a self-administered questionnaire, or a computer-generated evaluation. No matter how the information is collected, discussion of the findings is imperative. Health risk appraisals traditionally compare an
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individual's health-related behaviors and personal characteristics with mortality statistics and epidemiological data in order to estimate the risk of dying at some future specified time. These instruments rely on self-report, physiological measurements, and computer-assisted calculations; however, the highly quantitative presentation of the data and the risk projections provided may not be completely understood by the clients. Thus, their efficacy is lessened. The accuracy of the arithmetic predictions also has been questioned. Cohen and Stromborg 2 identified instruments available for purchase; however, few focus specifically on cancer risks. Conceptualizing the magnitude of cancer risk factors when their deleterious effects may not be manifest for many years remains difficult,s Although we live in a risk-conscious society, widespread misperceptions of risk exist across a broad spectrum of societal sectors. 9 The public fails to understand the concept of attributable risk and tends to focus instead on industrial and environmental toxic pollutants, which account for 10% or fewer of cancer deaths. 10 People in general appear to be less tolerant of these involuntary exposures than to those readily modified by changes in living
patterns. Some remain reluctant to be informed of their risks and may react with denial, fear, anger, or guilt when faced with their risk. 2 These and all other obstacles to effective communication must be addressed by providing risk information in a clear, concise, nonjudgmental manner. The University of Texas M.D. Anderson Cancer Center has developed CheqUp TM , a health risk assessment instrument specifically designed to address some of these concerns (Fig 2). CheqUp TM is a self-administered questionnaire that elicits demographics, life-style characteristics, family medical history, health practices, and screening status relevant to cancer and cardiovascular disease. The questionnaire is designed for use with an optical scanning device for error-free batch processing. CheqUp TM uses algorithmic logic based on empirical epidemiological data to program individualized feedback to clients. Quantitative feedback about risk, age, life expectancy, or risk of death is not provided. A computer program generates laserprinted individualized letters to clients. The information in the letter is confidential, rapidly responsive, and easily understood, although it may require further elucidation and interpretation in an individual session with a nurse educator. It identi-
36. How often do you eat chicken or other poultry with skin? Sometimes 37. How often do you eat the fat on meat? ~eldom/new Sometimes 3ften/alwa~ 38. What type of fat do you usually use in cooking and/or at the table? Margarine
m Vegetable oil Lard (animal fat, bacon drippings) ILI[O]InMI~IKOv]~l
39. How often do you eat whole wheat bread, high-fiber cereals, or dried beans and peas? Seldom Daily
Fig 2, CheqUp" (Cancer and Health Evaluation Questionnaire-User Profile) uses 67 questions (4 are presented hero) in a Scantron format to profile a patient's cancer and cardiovascular disease risks (Adapted w i t h permission. ~ )
CANCER RISK AND EARLY DETECTIONASSESSMENT
ties and explains site-specific risks for cancer and characterizes cardiovascular risk status. The letter specifically emphasizes actions to be taken and reinforces healthful life-style practices. Cancer screening recommendations are based on the risk data and family history information provided by the respondent. In introductory paragraphs, the letter thanks the patient for returning the CheqUp TM questionnaire and in a friendly tone comments on basic aspects that affect health such as smoking habits ("As a smoker, you probably know the many reasons you should quit"), weight, and diet ("From the information you have given us, it appears that you are eating a sensible low-fat diet"). The letter is then divided into fewer than 10 brief sections (eg, Heart Disease, Breast Cancer, Diet Tips) that briefly discuss incidence, symptoms, risks, and screening recommendations and specifically relate that information to the patient's questionnaire responses ("Your last Pap test was within the past 2 years. Continue to have regular Pap smears on the schedule that your physician indicates is appropriate for you"). The two- or three-page letter closes with the recommendation that patients discuss it with their physicians during their next examination. PHYSICAL ASSESSMENT BY SITE
The basics of the physical examination have been described in detail elsewhere. 1.3.4 This article highlights issues in the screening examinations for skin and head and neck cancer, breast cancer, male genitourinary cancer, gynecologic cancer, colorectal cancer, and lung cancer. Suggestions for incorporating early detection methods into clinical practice follow. Skin and Head and Neck Cancer
Skin cancer is the most common cancer, and its incidence continues to rise. 11 The elderly, who have been exposed the longest to solar rays, are at greatest risk, and 40% to 50% of those who live to be 65 years old will have at least one skin cancer. Persons at high risk should be encouraged to have a professional examination once a year, and they should be taught how to perform a skin selfexamination. 1,4 After appropriate training, nurses can incorporate skin cancer assessment and examination into everyday clinical practice. The skin assessment should not be postponed until a peri-
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odic physical examination because many seek medical attention only when ill. The increase in melanoma increases the importance of skin assessment, especially for those living in the Sun Belt. Nurses who perform head and neck screenings should review the patient's file or question the patient to find any evidence of factors increasing head and neck cancer risk (eg, tobacco use, poor oral hygiene, or high consumption of salted fish). Reviewing symptomatology (Does the patient have unilateral nasal obstruction or discharge, dysphagia, hoarseness, cervical adenopathy, or skin ulcerations?) and systematically performing a physical examination (inspection and palpation) of the head and neck are fundamental to early detection. 12 Breast Cancer
In 1992, the National Cancer Institute (NCI) revised the lifetime probability of an American woman developing breast cancer to one in eight, 13 heightening screening's importance. Optimal screening for breast cancer includes the triad of clinical examination, mammography, and breast self-examination (BSE) as routine health practice. The physical examination, performed by a nurse or physician, includes inspection, palpation, and a check for and evaluation of nipple discharge. Physical examination permits the discovery of cancers that appear in the intervals between regular screening or those cancers not detectable by mammography (masses in dense breasts of young women). 14 The quality and effectiveness of clinical breast examination for women of all ages must be improved, especially if the nurse or physician is to teach BSE. 15 Although techniques vary, nothing substitutes for a thorough 2- to 5-minute examination of the woman sitting upright with arms elevated and lying supine. 14'16 Mammography has unequivocal support as a screening procedure in women more than 50 years of age and has been shown to be beneficial in women younger than 50 years of age. Women over 50 years of age who had a screening mammogram and a physical breast examination between 40 and 49 years of age showed a 30% reduction in breast cancer mortality as compared with an unscreened group. 17 Women 40 to 49 years of age who were regularly screened had a significant reduction in breast cancer mortality.4'18 Underscoring their belief in screening in this group, the NCI, the Amer-
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ican Cancer Society (ACS), the American College of Radiology, and nine other professional medical organizations recommend that women 40 to 49 years of age have a mammogram every 1 to 2 years) 9 These same organizations also recommend annual mammography for women 50 years of age and older. Breast self-examination (BSE), although not technically a method for detecting cancer in its earliest stages, is recognized as an adjunctive technique for cancer detection, and practicing BSE does have advantages. 2~ In one study, women who practiced BSE sought medical care more rapidly and were diagnosed at an earlier stage of disease than women who did not, and after 5 years there was a significant difference (p < .0001) between the survival rates of self-examiners and non-selfexaminers. 21 This work confirmed earlier findings. 22 One-on-one personal instruction is necessary for women to become regular self-examiners, z3 One study found that having confidence in the ability to perform BSE correctly also increased the likelihood of practicing it. Not associated with confidence was simply reading about BSE. Maternal history of breast disease, living with a sexual partner, and lacking fear that breast loss would compromise attractiveness also positively affected BSE practice. 23 Champion 2~ reported that addressing attitudes and beliefs that pose barriers to practicing BSE can significantly improve BSE proficiency and frequency. 2~Champion, along with Foster and colleagues, 15 has called for intensifying efforts to improve proficiency in BSE and clinical breast examination. Most women do not practice BSE, and in one study only 26% of nurses were found to regularly practice BSE, although 68% believed BSE had definite value. 24 Nurses, who are a "lifeline" to patients with cancer, 25 can be no less to asymptomatic patients who are uninformed about how to reduce breast cancer risk and how to detect it. Nurses who want to encourage regular BSE in their patients should practice BSE personally and teach it individually, stress regularity in practice (eg, making notes in a journal, keeping a record, or reinforcing practice with a reward), emphasize the importance of prompt medical advice after an irregularity is detected (teach women about stagedependent prognosis), and reinforce the benefits of having a physician who supports BSE. Simplifying
BSE technique, emphasizing family in motivating performance, and individualizing instruction and technique are just three of several ways that have been suggested to improve outreach. 14.2o Male Genitourinary Cancer
Prostate and testicular cancer represent over one fifth of all cancer cases in men. Prostate cancer occurs most frequently in men 50 years of age and older, whereas testicular cancer, which accounts for about 1% of cancer cases in men, most commonly occurs in the young (15 to 40 years of age). Prostate cancer is twice as common in blacks as in whites. Because prostate cancer occurs most commonly in older men, its symptoms may be mistakenly attributed to aging. These symptoms include nonspecific urinary symptoms--frequency, dysuria, complete urinary retention, and hematuria. Often symptoms are indicative of late complications .4 The digital rectal exam (DRE), measure of prosrate-specific antigen (PSA), and transrectal ultrasonography are the three methods used to screen for prostate cancer. The Prostate Cancer Detection Clinic at The University of Texas M.D. Anderson Cancer Center uses all three, and the Cancer Prevention and Detection Programs for Nurses teaches nurses complete male genitourinary assessment through its comprehensive training programs. In the DRE, the prostate is palpated transrectally to detect changes in size, shape, contour, consistency, and borders. 26 Specific steps in the DRE are outlined elsewhere. 1,z7 PSA, which is more sensitive than specific, helps monitor disease and is currently being investigated as a screening method, along with transrectal ultrasonography and DRE, in the multicenter American Cancer Society National Prostate Cancer Detection Project trial. 28 Evidence continues to mount indicating that family history may be a risk factor for prostate cancer. Practical application of this knowledge to screening involves combining the detection methods in men with familial patterns. Reports indicate that risk may be doubled for men whose father or brother has a history of prostate cancer. In these men, DRE, serum PSA assays, and transrectal ultrasonography might be used for screening. 29 The nurse or physician can be especially valuable in teaching men 40 years of age and older the importance of regular professional examinations.
CANCER RISK AND EARLY DETECTION ASSESSMENT
Counseling improves compliance by increasing knowledge and dispelling myths. 29 Men who have a family history of prostate cancer need regular yearly examinations and should request them if not recommended by their physician. Elderly men who are especially at risk--80% of cases occur in men 65 years of age or olderl'29--may be geographically isolated or infirm and need special programs, such as a mobile screening effort, to obtain regular screening. Cohen and Frank-Stromborg2 advised that when elderly men are hospitalized, neither nurse nor physician should be deterred by a chart that reads "rectal exam deferred" and should determine whether the patient has had an exam within the last year. Furthermore, any professional who is unable or too embarrassed to perform a DRE should secure someone to perform the examination. Nurses who wish to develop skills in male genitourinary screening examinations can be trained at workshops or by participating in the ACS prostate screening project. Although rare, testicular cancer is the most common cancer in males 15 to 40 years of age. Typically these young men postpone seeking treatment about 6 months, thereby losing the advantage of earlier detection and prompt treatment. Young men appear to know little of the indications of the disease but have demonstrated an ability to respond to instruction. 3~ They need to know that unilateral enlargement of the testicles, the appearance of nodules or lumps, or changes in testicular consistency are conditions needing prompt medical attention. The ACS recommends that men have a professional testicular assessment annually and that they perform testicular self-examination (TSE) monthly beginning in puberty, l~ Nurses or physicians may estimate the weight and equality of size of each testis by holding a testis in each hand, lifting them, and then pulling them forward gently in the scrotal sac. Palpation of the testes, epididymis, and vas deferens is performed to detect any abnormalitiesY No prospective randomized trial of TSE has confirmed its effectiveness in detecting cancer early, and the US Preventive Services Task Force (USPSTF) found insufficient evidence to recommend TSE. 31 Nonetheless, recognizing that the USPSTF recommendations addressed the quality of existing scientific evidence more than standards of care, the NCI still recommends TSE. ~1
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Gynecologic Cancer Nurses who become proficient in performing pelvic examinations are an asset to nursing, to the community, and to a physician's practice. Patients are pleased and satisfied with examinations performed by nurses, and the examinations are also more cost effective. Nurses can reach the inadequately served population who may be at highest risk, including older women or poor women. Nurse colposcopists expand the outreach capability even more. Cervical cancer detection has been compromised by controversy over effective use of the Papanicolaou (Pap) smear to identify cervical cancer and its precursors. Controversial failings of current screening include patient error (eg, failure to have follow-up examinations, delay in seeking medical attention), physician error (failure to do pelvic examination with Pap test or to act on abnormal cytological findings), and laboratory error (smears inaccurately read). 32 Reducing the proportion of false-negative smears and increasing uniformity in reporting cervical smears are goals of the Bethesda reporting system, quality control measures imposed by Congress on cytology laboratories, and quality control monitoring by automated cytological preparation scanning devices. 33,34
To restore faith in the workability and validity of screening and to ensure the accessibility of testing to as many women as possible, Cohen and FrankStromborg2 recommended that nurses educate all women about the early symptoms of gynecologic cancer and the need to seek advice, as well as about recommendations for Pap smear screening. Women with a history of abnormal or questionable findings should be encouraged to call rather than rely on being called about Pap findings. Whenever results are abnormal or questionable, women should be counseled about having regular followup examinations and receiving additional medical care if needed. Older women should be taught to ask for a Pap smear when they have a physical examination. To help reduce laboratory error, physicians and nurses need to perfect their smeartaking skills. 1,35,36 Laboratory reliability, perhaps now enhanced by quality control measures, can maintain or further improve reliability by restricting the workload, improving training, and nurturing cooperative communication between the pathologist and the smear provider. 32 Nurses should
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strive to inform young women about having Pap smears as soon as they become sexually active. 4 Health professionals caring for older women in retirement centers, extended care facilities, or other settings should educate them about signs and symptoms of gynecologic cancers and stress the importance of having gynecologic exams after menopause. Older women need to know that certain premalignant conditions place them at higher risk for certain gynecologic cancers. 4 Women taking estrogen need to be routinely monitored for early detection of endometrial cancer, s Health professionals also should be aware of physical changes in older women that make pelvic examinations and Pap smears uncomfortable. Decreased mobility of the femoropelvic structure and narrowing of the vaginal orifice may make examinations more painful. The left lateral Sims' position instead of the lithotomy position has been used to ease the discomfort caused by lack of mobility.
Colorectal Cancer Colorectal cancer is a leading cause of death in men and women older than 35 years of age and the second most common cancer in the United States.1 ~ Screening recommendations are based on age and both personal and family history. The recommendations of the ACS, the American Gastroenterological Association, the NCI, the American College of Physicians, and the World Health Organization Collaborating Center for Prevention of Colorectal Cancer are similar, requiring annual fecal occult blood testing and flexible sigmoidoscopy every 3 to 5 years beginning at 50 years of age. s7 The ACS also recommends an annual DRE every year after 40 years of age. The feasibility of periodic colonoscopy or barium enema for those over 60 years of age requires study. Controversy exists over fecal occult blood screening because of questions of effectiveness, high false-positive rates, and high cost of followup testing, and poor compliance. Analyses currently under way of large-scale fecal occult blood screening studies should yield information about mortality reduction. New screening tests are needed and are being developed, including immunochemical tests that detect bleeding and other changes caused by cancer. 4'37 In the future, more specific and sensitive molecular techniques may detect abnormal genetic elements in stool or b l o o d y Recent work supports the value of screen-
ing sigmoidoscopy. In one study, those screened had a 60% to 70% lower risk of death from rectal or distal colon cancer than those not screened. 38 In a retrospective case-control review, researchers concluded that screening sigmoidoscopy could substantially reduce mortality from rectal and distal colon cancers. 39 Health professionals who correct misconceptions about colorectal cancer and Americans' knowledge about it perform an important service. Advising people about colorectal cancer's common occurrence yet reassuring them that this cancer does not necessarily result in a permanent colostomy helps change their concept of the disease. Health professionals can also encourage more healthful eating habits by advising patients to avoid obesity; to decrease total fat intake to about 30% of total calories; to eat more high-fiber foods, foods high in vitamins A and C, and cruciferous vegetables; and to consume alcoholic beverages and salt-cured, smoked, and nitrite-cured foods in moderate or lower amounts. 4'7
Lung Cancer Cigarette smoking is the largest preventable cause of premature death and disability and the major single cause of cancer mortality. In 1988, Texas statistics indicated that of the total $4.3 billion cost of cancer for that year, 25% could be attributed to lung cancer exclusively.4~ Smoking, an expensive, debilitating, and time-consuming habit six to eight times as addicting as alcohol, 41 is responsible for 87% of lung cancer deaths and 30% of all cancer deaths.S'11 Because lung cancer gives no early clues and most symptoms are those of advanced disease, primary prevention offers the best hope of combating this cancer. Most smokers begin smoking in adolescence; thus, preventive efforts should begin early. Smoke-free policies in businesses and public places restrict time available for smoking and increase social pressure on the smoker to quit. Multiple approaches appear to work best in trying to get someone to stop smoking: recommendations from both physicians and nonphysicians, recommendations on multiple occasions, individualized and direct face-to-face advice, materials that are educationally and culturally relevant, referral to cessation programs, scheduled reinforcement, and drug therapy. 4 Having available reminders of why quitting is beneficial may help quitters persevere in
CANCER RISK AND EARLY DETECTION ASSESSMENT
their resolution to stop (Table 1). The decrease in physicians who smoke, from approximately 50% in the 1950s to less than 20% in the 1980s, has had a profound effect on patients' smoking practices, is Although among nurses, smoking is declining and cessation rates are increasing, nurses have failed to reduce smoking in their professional ranks as dramatically as other health professionals and have been reprimanded for the lost opportunity to set a good example. 18.25,43 INCORPORATING EARLY DETECTION INTO CLINICAL PRACTICE
Every physician's office and every clinic examining room can become a cancer screening center Table 1. The Benefits of Quitting Smoking
The same great benefits go to all quitters, and they start right away. Soon after your last cigarette, your body starts to heal itself. Look at these benefits: After 20 Minutes Your pulse, blood pressure, and body temperature return to normal as nicotine is filtered out of your body. After 12 Hours The carbon monoxide level in your blood returns to normal. After 24 Hours Your circulation and fine motor coordination improve. After 6 Weeks Your smoker's cough begins to disappear. After 3 Months Your senses of smell and taste improve; stamina and endurance increase; immune system improves. After 1 Year Your risk of coronary heart disease is half what it was when you were a smoker. After 5 Years Your risk of cancers of the mouth, throat, and esophagus decreases by half. After 5-15 Years Your risk of stroke becomes the same as that of peop|e who've never smoked. After 10-15 Years Your risks of premature death, lung cancer, bladder cancer, and peripheral artery disease go down significantly. Your risk of coronary heart disease is as low as that of someone who's never smoked at all. Adapted with permission from Break Clear TM, the smoking cessation component of Life Cheq TM Cancer Prevention Program, Division of Prevention. The University of Texas M.D, Anderson Cancer Center (713) 792-3011.42
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without reorganizing office or clinic procedure, without hiring new personnel, and without major investments of time or money. The task of reducing the morbidity and mortality of cancer and enhancing health in a population of patients begins with a commitment to a goal, planning, and restructuring the project into manageable tasks. Pommerenke and Smart44 urged the implementation of early cancer detection efforts by primary care practitioners and named ways of modifying practice to save lives through prevention. Physicians and nurses can engage patients in a health partnership aimed at controlling cancer by reducing cancer risk and improving early detection. This effort expands beyond the office walls as the patient incorporates changes in life-style to reduce risk and perhaps influences others to do the same,
The risk assessment can be incorporated into the medical history review by making the risk questions part of the history questionnaire or by evaluating cancer risks separately. Answers are usually written on a form by the patient or obtained during an interview by the nurse. Discussion with the patient of risk-related behaviors, such as smoking or diet, is important, but following through with screening procedures and recommendations is also critical. Why compile a risk profile and fail to review and interpret the assessment or fail to include cancer detection techniques in the physical examination? Why perform a Pap smear and fail to follow up with more frequent screenings for those needing them? Nurses should consider these specific suggestions: (1) discuss risk reduction during a review of assessment, when scheduling the follow-up visit, or before or after the examination; (2) encourage patients to observe regular screening guidelines to practice self-examination and to expand what they have learned; (3) supply written materials supporting the message so that patients who are shy, uncomfortable, or nervous during an office visit can review the material in the privacy of their home; and (4) use color-coded file stickers or program the computer system as reminders of which patients need to schedule follow-up visits. Some offices complete follow-up reminder cards at the time of the visit for later mailing. Elderly patients need care beyond the support that is offered to the typical asymptomatic patient. Elders need nurses to be advocates to learn about their socioeconomic concerns, to listen actively
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and encourage meaningful conversation, to understand their fear of cancer, and to respect their more private and more reticent ways. An elderly woman who claims she just wants a "check for cancer" may have symptoms or signs of disease that she will not divulge unless she is encouraged and made to feel secure. Elder advocates can hold clinics in nursing homes, senior centers, geriatric day-care centers, and retirement homes where large populations of the elderly live. 5 Oncology nurses are role models and leaders in cancer control efforts. Because health professionals have been trained to address the diagnostic and therapeutic expectations of patients, they are often unsure of how to proceed with risk assessment and intensive interventions. They are familiar with the basic risk factors but lack understanding of the interactions of these factors and exact risk magnitudes. Researchers surveyed members of the American Society of Clinical Oncology and concluded that oncologists were " a major untapped potential resource for implementation of CPC (cancer prevention and control) objectives." The researchers determined that if oncologists incorporated cancer prevention and detection education into their own practices, it would increase prevention and detection in the practices of other health professionals because the oncologists were perceived as leaders in their field. 45 No less could be said of oncology nurses. One of the barriers perceived by these oncologists was that they lacked patients without cancer. Admittedly, discussing cancer prevention with pa-
tients who already suffer from a diagnosed neoplasm is a delicate issue, but the existent cancer does not nullify the nurse's responsibility to assess other existing or potential health problems and to intervene. Patients with cancer who face increased risk for other cancers must first be allowed to meet the emotional and physical challenges of existing disease before being counseled about other cancers and changes in life-style. Incorporating early detection tests into the patient's workup and discussing the test results at a time when the patient has the reserve for health promotion is advisable. SUMMARY
Nurses and physicians form an ideal corps for implementing cancer prevention and early detection efforts: providing health education, promoting health enrichment, defining high-risk groups and identifying patients who belong to them, and providing screening to ensure early diagnosis and prompt treatment. A personal medical history, a history of exposures in life-style, and a family history form the foundation for cancer risk assessment. The physical examination that follows takes into account the incidence and indications of cancer at various sites and the patient's risk profile. Health professionals can incorporate screening techniques into everyday practice by gathering information in the medical history, incorporating cancer detection in the physical examination, following up with more frequent screenings or referrals for those needing them, and becoming cancer detection advocates among patients and professional peers.
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