Does she warrant a malignancy screen?

Malignancy Screening Recommendations

Malignancy screening should only be pursued if the patient has specific risk factors or clinical features that suggest a paraneoplastic process, as routine screening in the absence of these factors is not recommended. 1

When to Consider Malignancy Screening

Malignancy screening is warranted in the following specific scenarios:

• Rapidly progressive diffuse cutaneous systemic sclerosis (dcSSc) 1
• Unexplained weight loss 1
• Elderly patients with suspicious clinical features 1
• Presence of anti-RNA polymerase III antibodies (anti-RNAPIII), which increases malignancy risk 1
• Other high-risk features such as:
  • Interstitial lung disease (ILD) 1
  • History of cyclophosphamide use 1
  • Prior autologous hematopoietic stem cell transplantation (AHSCT) 1

Screening Approach

When malignancy screening is indicated based on the above risk factors, follow these evidence-based guidelines:

1. Follow age-appropriate cancer screening guidelines as recommended for the general population:

   • Mammography for breast cancer 1
   • Pap tests for cervical cancer 1
   • Colonoscopy or other approved methods for colorectal cancer 1

2. Additional surveillance:

   • Periodic urine microscopy if the patient has been exposed to cyclophosphamide 1
   • Consider more targeted investigations based on specific symptoms or laboratory abnormalities

Important Considerations

• Routine malignancy screening in patients without the specific risk factors mentioned above is not supported by current evidence and may lead to unnecessary testing, anxiety, and potential harm 1, 2

• False-positive results from screening tests can lead to additional invasive procedures with limited yield. A study of clinically node-negative breast cancer patients found that even when preoperative screening tests were abnormal, metastasis was present in less than 1% of patients 3

• The positive predictive values of routine preoperative complete blood count, liver function tests, and chest X-ray for occult metastasis are extremely low (1.3%, 1.1%, and 1.5%, respectively) 3

• Newer multicancer detection tests using blood samples are being studied but have variable sensitivity (27-95%) that differs by organ site and cancer stage, with lower sensitivity for early-stage cancers when treatment would be most effective 4

Clinical Pitfalls to Avoid

• Don't perform routine malignancy screening in all patients without specific risk factors, as this can lead to unnecessary testing and potential harm 1, 3

• Don't overlook the importance of age-appropriate cancer screening that is recommended for the general population, which should still be performed according to established guidelines 1

• Don't ignore new or unexplained symptoms that could indicate an underlying malignancy, even if routine screening tests are negative 1

• Don't rely solely on normal screening tests to rule out metastasis, as studies show that normal results do not exclude the possibility of malignancy 3

By following these evidence-based recommendations, clinicians can appropriately identify patients who would benefit from malignancy screening while avoiding unnecessary testing in those at low risk.