What are the key points in secondary cancer screening?

Secondary Cancer Screening: Key Points

Cancer survivors should undergo standard population-based screening for new primary cancers according to American Cancer Society guidelines, with enhanced surveillance only for specific high-risk scenarios including lung cancer screening in head and neck cancer survivors with significant smoking history, and genetic counseling for those with bilateral breast cancer or strong family history. 1, 2

Core Principle: Standard Screening for Most Survivors

• Routine advanced imaging (CT, MRI, PET/CT, bone scans) should NOT be performed for screening asymptomatic cancer survivors, as randomized trials from the 1980s demonstrated no survival advantage and showed significant rates of false-positive findings requiring additional testing 1

• Cancer survivors should follow the same age-appropriate screening guidelines as the general population for cervical, colorectal, endometrial, and lung cancers 1

• Radiologic imaging should only be ordered when disease recurrence is suspected based on clinical signs or symptoms 1

Site-Specific Enhanced Surveillance

Breast Cancer Survivors

• Annual mammography and clinical breast examination should continue for life 1

• Postmenopausal women taking tamoxifen or other SERMs require annual gynecologic assessment and should report any vaginal spotting or bleeding immediately, but routine pelvic imaging is not recommended in asymptomatic patients 1

• Genetic counseling is mandatory for bilateral breast cancer regardless of age at diagnosis, as this constitutes sufficient indication for BRCA1/2 testing even without additional family history 2

Head and Neck Cancer Survivors

• Annual lung cancer screening with low-dose CT (LDCT) is recommended for high-risk patients based on smoking history (≥20 pack-years, currently smoking or quit within 15 years, ages 50-80) 1

• Approximately 23% of head and neck cancer survivors develop second primary cancers, with 89% occurring in the head/neck, lung, or esophagus 1

• Enhanced surveillance for another head and neck or esophageal cancer should be performed as for patients at increased risk 1

Colorectal Cancer Survivors

• Surveillance colonoscopy at 1 year post-surgery, then every 5 years if normal 1

• If complete colonoscopy was not performed before diagnosis, perform as soon as reasonable after completing adjuvant therapy 1

• The incidence of secondary colorectal cancers remains elevated (standardized incidence ratio 6.8) despite intensive surveillance 1

Melanoma Survivors

• At least annual full-body skin examination for life 1

• Monthly self-skin examination and self-lymph node examination for stage IA-IV with no evidence of disease 1

• For stage IIB-IV with no evidence of disease, consider chest x-ray, CT, and/or PET/CT scans every 6-12 months and brain MRI annually (category 2B recommendation), but routine imaging is not recommended after 5 years 1

Genetic Risk Assessment

When to Refer for Genetic Counseling

• Bilateral breast cancer at any age 2

• Breast cancer diagnosed before age 50 years 1

• Triple-negative breast cancer diagnosed at age ≤60 years 1

• Ashkenazi Jewish heritage with breast cancer 1, 2

• First-degree relative with breast cancer before age 50 years 1

• Two or more first- or second-degree relatives with breast cancer at any age 1

• Personal or family history of ovarian cancer 1

Genetic Counseling Components

• Multi-gene panel testing should include BRCA1/2 as primary targets, with consideration of moderate- to high-penetrance genes (TP53, PALB2, CHEK2, ATM, RAD51C, BRIP1) based on personal and family history 2

• Detailed three-generation pedigree analysis from both maternal and paternal sides 2

• Discussion of test result implications for medical management, surveillance, and family members 2

• Genetic counseling should occur before starting treatment when possible, as results may inform surgical and systemic therapy decisions 2

Common Pitfalls to Avoid

• Do not use general breast cancer risk models (e.g., Gail model) to determine who needs genetic counseling, as these are not designed for hereditary cancer assessment 2

• Never perform genetic testing without adequate pre-test counseling by an appropriately trained professional 2

• Do not delay genetic counseling until after treatment completion, as this misses opportunities to inform surgical and systemic therapy decisions 2

• Avoid routine blood tests for cancer surveillance in asymptomatic melanoma survivors, as they are not recommended 1

• Do not screen with whole-body PET or PET/CT in asymptomatic patients, as these frequently yield equivocal findings requiring further evaluation without proven survival benefit 3

Patient Education Requirements

• Educate all cancer survivors about specific signs and symptoms of local or regional recurrence relevant to their primary cancer type 1

• For breast cancer survivors: new lumps (underarm or neck), rash or skin changes on breast/chest wall, chest pain, changes in breast contour/shape/size, breast or arm swelling 1

• For head and neck cancer survivors: swelling in head/neck, non-healing areas, red or white oral patches, persistent sore throat, foul oral odor, nasal obstruction, nosebleeds, difficulty breathing, double vision, numbness/weakness, ear or jaw pain, difficulty chewing/swallowing, blood in saliva, loose teeth, ill-fitting dentures, unexplained weight loss or fatigue 1

• Counsel patients to adhere to adjuvant endocrine therapy for breast cancer, as adherence ranges only 50-92% but is necessary to achieve survival benefits 1

Surveillance Intensity Based on Risk

• Follow-up schedule should be influenced by risk of recurrence, prior primary malignancy, and family history 1

• For melanoma stage 0 (in situ): history and physical examination with emphasis on nodes and skin every 3-12 months for 5 years, then annually 1

• For melanoma stage IA-IIA with no evidence of disease: history and physical every 3-6 months for 2 years, then every 3-12 months for 3 years, then annually; routine radiologic imaging NOT recommended 1

• For colorectal cancer survivors: medical history, physical examination, and CEA testing every 3-6 months for 5 years, with frequency driven by the fact that 80% of recurrences occur in the first 2-2.5 years and 95% by 5 years 1