Cancer Screening and Prevention Programs

Yale New Haven Hospital offers breast and cervical cancer screening; as well as heart healthy services for uninsured and underinsured women.

As part of the Connecticut Breast and Cervical Cancer Early Detection Screening Programs (CBCCEDP), Yale New Haven Hospital is one of the sites in Connecticut offering a comprehensive breast and cervical cancer screening program for medically underserved women. Services such as mammograms, clinical breast exams and Pap smears are offered free of charge for eligible women over age 40.

Yale New Haven also offers the WISEWOMAN (Well-Integrated Screening and Evaluation for Women Across the Nation) Project. WISEWOMAN assesses risks of heart disease and provides preventive health services to medically underserved women. Connecticut is one of only seven states to adopt WISEWOMAN, with YNHH as one of the nine sites in the state to administer the program.

For more information on these programs, please call 203-688-2219 or 203-867-5436.

Who should be screened for Breast Cancer?

• All average-risk women ages 40 and older should receive annual screening mammograms
• Women who are at an increased lifetime risk of breast cancer due to strong family history, known genetic mutations that are associated with breast cancer, and/or received chest radiation for other cancer or conditions between the ages of 10 and 30 may consider screening before age 40. They should talk to their health care providers about when and how to screen for breast cancer. For more information, see below.

For women who are at average risk for breast cancer

As you may have heard, the American Cancer Society recently changed their recommendations for breast cancer screening. However, many other medical organizations, such as the American College of Radiology, the Society of Breast Imaging, and the American College of Obstetrics and Gynecologists continue to recommend annual screening mammography starting at age 40. Because the risks and benefits of cancer screening depend on a number of individual factors such as your age, medical history, race and/or ethnicity, family history, and breast density, doctors at Smilow continue to recommend annual screening mammograms beginning at age 40 for most average risk women. However, you should discuss the screening schedule that is best for you with your health care provider.

For women at higher than average risk

Women who are at an increased risk for breast cancer due to strong family history or certain other risk factors should discuss the option of screening MRI with their physician. These women should also continue with annual mammograms. For more information, see below: Who should have an MRI?

It is generally recommended that all women be familiar with the normal look and feel of their breasts and report any changes to their doctor or health care provider right away.

What tests are available through the Smilow Screening and Prevention Program?

Mammograms and other breast imaging tests are available at Smilow Cancer Hospital. However, you can also get these tests at the Long Wharf facility at Sargent Drive in New Haven, at Devine Street in North Haven, and at the Shoreline Medical Center in Guilford as well as through our mobile mammography service.

• Mammogram or Mammography
  A mammogram is an x-ray examination of your breasts to check for breast cancer. Sometimes a woman has a diagnostic mammogram because she has a problem with her breasts and she needs to be checked. However, most mammograms are part of a routine check–up in order to make sure that no cancer is present; this is called a screening mammogram.
• Tomosynthesis
  At Smilow, we use tomosynthesis, or 3D mammography. Tomosynthesis allows the radiologist to view the breast in thin "slices" rather than as a whole and improves the detection of lesions and reduces false alarms due to overlapping normal tissues. The 3D imaging is performed simultaneously with the 2D mammogram so the length of the exam does not change. This new test does not change the patient’s experience; it feels the same as a regular mammogram. While tomosynthesis may involve a small increase in the radiation dose, the total radiation dose remains below the federal standards for mammography. Tomosynthesis improves not only the outcomes of screening, but also the accuracy of diagnostic radiology and biopsy recommendations. Tomosynthesis is available at all locations except the mobile mammography service.
• Breast Ultrasound
  Sometimes it is necessary to supplement the mammography findings with a breast ultrasound on one or both breasts. This is especially helpful in the case of dense breasts.* Connecticut law requires that all women receive information about their breast density in their mammography results. Women who have dense breasts (labeled as heterogeneously or extremely dense) may be offered a breast ultrasound in addition to their mammogram. Under Connecticut law, insurance companies must pay for this test.
• What is breast density? *
  Breast density describes the pattern of breast tissue that is seen on a mammogram. It is NOT something that can be felt through touch. Although dense breasts are common, particularly in women before menopause, having heterogeneously or extremely dense breasts makes it more difficult to read a mammogram and may increase a woman’s risk of breast cancer.
• MRI (Magnetic Resonance Imaging)
  MRI is a procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body. MRI does not use any x-rays so has no radiation dose. Breast MRI does require the use of a contrast agent through an intravenous line placed in the arm prior to the exam.

Who should have an MRI?

For women at higher than average risk

Women who are at an increased risk for breast cancer due to strong family history or certain other risk factors should discuss the option of screening MRI with their physician. These women should also continue with annual mammograms.

This includes women who:

• Have a lifetime risk of breast cancer of about 20% to 25% or greater, according to risk assessment tools that are based mainly on family history
• Have a known BRCA1 or BRCA2 gene mutation Have a first-degree relative (parent, brother, sister, or child) with a BRCA1 or BRCA2 gene mutation and have not had genetic testing themselves
• Had radiation therapy to the chest when they were between the ages of 10 and 30 years
• Have Li-Fraumeni syndrome, Cowden syndrome, or Bannayan-Riley-Ruvalcaba syndrome, or have first-degree relatives with one of these syndromes

For women at moderately increased risk

There’s not enough evidence to make a recommendation for or against yearly MRI screening for women who have a moderately increased risk of breast cancer (a lifetime risk of 15% to 20% according to risk assessment tools that are based mainly on family history) or who may be at increased risk of breast cancer based on certain factors, such as:

• Having a personal history of breast cancer, ductal carcinoma in situ (DCIS), lobular carcinoma in situ (LCIS), atypical ductal hyperplasia (ADH), or atypical lobular hyperplasia (ALH)
• Having dense breasts (“extremely” or “heterogeneously” dense) as seen on a mammogram

If MRI is used, it should be in addition to, not instead of, a screening mammogram. This is because although an MRI is a more sensitive test (it’s more likely to detect cancer than a mammogram), it may still miss some cancers that a mammogram would detect.

For most women at high risk, screening with MRI and mammograms should begin at age 30 years and continue for as long as a woman is in good health. But because the evidence is limited about the best age at which to start screening, this decision should be based on shared decision-making between patients and their health care providers, taking into account personal circumstances and preferences.

The Smilow Screening & Prevention Program is aligned with the American Cancer Society guideline for Cervical Cancer early detection.

Who should be screened for Cervical Cancer?

• All women at age 21 to 29 should have a Pap test every 3 years. HPV (Human PapillomaVirus) testing screening in this age group may be used as a part of follow up for an abnormal Pap test.
•  Beginning at age 30 until age 65, the preferred way to screen is with a Pap test combined with an HPV test every 5 years or every 3 years with just the Pap test.
• Women who are at high risk of cervical cancer, have been diagnosed with cervical cancer, cervical pre-cancer, or HIV infection should follow the recommendations of their health care team.
• Women over 65 years of age who have had regular screening in the previous 10 years should stop cervical cancer screening as long as they haven’t had any serious pre-cancers (like CIN2 or CIN3) found in the last 20 years.
• Women with a history of CIN2 or CIN3 should continue to have testing for at least 20 years after the abnormality was found. Women who have had a total hysterectomy (removal of the uterus and cervix) should stop screening with Pap tests and HPV tests, unless the hysterectomy was for treatment for cervical pre-cancer (or cancer).
• Women who have had a hysterectomy without removal of the cervix (called a supracervical hysterectomy) should continue cervical cancer screening according to the guidelines above.
•  Women of any age should NOT be screened every year by any screening test unless the result has been abnormal*.

* Women who have abnormal screening results may need to have a follow up Pap test (sometimes with a HPV test) done in 6 months or a year.

Important

• Even if you have been vaccinated against HPV, you should still follow these guidelines.
• Even if you have stopped having children, you should still follow these guidelines.

Currently, no studies have shown that screening in head and neck cancer saves lives, but our own experience in head and neck screening at YNHH has shown that screening can identify cancers in patients that lead to cure. In addition, patients are frequently referred to Smilow’s Head and Neck Cancer Team after a community dentist or oral surgeon identifies a suspicious lesion.

Smilow doctors advise that all patients have yearly mouth and oropharynx cancer screening with their dentists during routine dental visits. In addition, examination of the neck, mouth, and oropharynx by their primary care physicians should be conducted at all routine physical examinations.

Who should be screened?

• All adults
• High risk patients for squamous cell cancer include those with history of using tobacco, heavy alcohol, betel nut, and multiple sexual partners

What tests are available through the Smilow Screening and Prevention Program?

• Extensive oral and head and neck physical examination
• Risk evaluation
• Education

Complete oral and head and neck cancer screening by a thorough physical examination is provided to patients by specialists in head and neck cancer throughout the year at various sites. Every April during Oral Head and Neck Cancer Awareness Week (OHANCAW), in collaboration with the Head and Neck Cancer Alliance, we host an outreach event.

For patients with a history of Head & Neck Cancer

Based on the NCCN guidelines, we recommend follow-up physical examination according to the following schedule:

• Year 1: every 1 to 3 months
• Year 2: every 2 to 4 months
• Years 3 to 5: every 4 to 6 months
• Year 5 and Beyond: every 6 to 12 months

Who should be screened for Lung Cancer?

Adults aged 55 to 80 years who have a 30 pack year smoking history and currently smoke or have quit within the past 15 years. One pack year = smoking one pack per day for one year; 1 pack = 20 cigarettes. Screening should be discontinued once a person has not smoked for 15 years.

Examples:

• If you smoked 1 pack of cigarettes (20 cigarettes) per day for 30 years, you have a 30 pack year smoking history
• If you smoked 2 packs (40 cigarettes) per day for 15 years, you have a 30 pack year history
• If you smoked 1 ½ packs (30 cigarettes) per day for 20 years, you have a 30 pack year history

What tests are available through the Smilow Screening and Prevention Program?

• Decision Support Visit
  
  Every patient referred for lung cancer screening is scheduled for a decision support visit with a Medical Doctor or Advanced Practice Provider from the Smilow Tobacco Treatment Program.
  
  At this visit, the risks and benefits of screening and individualized risk assessment are discussed with the patient. An educational module on lung cancer and screening is also offered to every patient.
  
  
• Low-dose CT (LDCT) of the chest
  
  This procedure uses low-dose radiation to make a series of very detailed pictures of areas inside the chest. It uses an x-ray machine that scans the body in a spiral path. The pictures are made by a computer linked to the x-ray machine. This procedure is also called a low-dose helical CT scan.

Who should be screened?

Prostate cancer is the most commonly occurring cancer in men. Whether or not a man should undergo screening for prostate cancer is an important decision. Because research has not yet proven that the potential benefits of testing outweigh the harms of testing and treatment, doctors at Smilow believe in a shared decision making approach in which the decision to screen should be made between a man and his health care provider. This decision should be made after an informed discussion of the risks and benefits of prostate cancer screening, taking into consideration a man’s age, race/ethnicity, health status and family history of prostate cancer. Because some men may be at higher than average risk, it is important that you discuss your risk status with your doctor.

Men at Average Risk:

Men in their 40’s: Doctors at Smilow feel that all men regardless of their known risk factors should have an opportunity to have a baseline PSA as this may help inform the discussion and decision about future screening.

At age 55: Men who are at average risk of prostate cancer should talk to their doctors about routine screening for prostate cancer. Doctors at Smilow agree with some professional organizations that biennial (every 2 years) screening may be adequate in this age group, as long as an initial age-adjusted PSA test was normal.

Over the age of 69: Doctors at Smilow recommend an individualized approach to screening that takes into consideration the man’s general health and life expectancy. It should be noted that some professional organizations do not support screening men in this age group.

Men at Greater than Average Risk:

At age 40, men who are at increased risk of prostate cancer should talk to their health care provider about prostate cancer screening.

This includes:

• African American / Black men (Men of African Ancestry)
• Men with a family history of prostate cancer in a first degree relative (father, brother, or son) diagnosed before age 65.

What tests are available through the Smilow Screening and Prevention Program?

If you decide to be tested, doctors at Smilow recommend both a PSA blood test and a rectal exam. How often you’re tested will depend on your PSA level.

• PSA
  PSA or Prostate- Specific Antigen can be measured with a blood test. Although there are different reasons that the PSA level may increase, it can be associated with prostate cancer.
• DRE
  Digital Rectal Exam is a test that is performed by your health care provider to evaluate the prostate; this test can help identify problems with the prostate gland.

According to the American Cancer Society most skin cancers are caused by too much exposure to ultraviolet (UV) rays. Some of this exposure may come from man-made sources, such as indoor tanning beds and sun lamps, but most of this exposure comes from the sun.

Some people think about sun protection only when they spend a day at the lake, beach, or pool. But sun exposure adds up day after day, and it happens every time you are in the sun.

Who should be screened for Skin Cancer?

Everyone should perform monthly head-to-toe self-examination of their skin. ¹

How do I protect myself from UV rays?

Simply staying in the shade is one of the best ways to limit your UV exposure. If you are going to be in the sun, “Slip! Slop! Slap!®and Wrap” is a catchphrase that can help you remember some of the key steps you can take to protect yourself from UV rays:

• Slip on a shirt
• Slop on sunscreen
• Slap on a hat
• Wrap on sunglasses to protect the eyes and skin around them

¹ Skin Cancer Foundation http://www.skincancer.org/