Cancer Prevention and Early Detection Nursing CE Course

ndards of Practice, nurses are encouraged to fulfill educational requirements in the principles of cancer prevention and early detection. Nurses can become skilled in assessing, evaluating, and interpreting cancer risk assessments and recommend appropriate cancer prevention and screening strategies. Furthermore, nurses provide culturally sensitive cancer prevention and early detection services, are involved in community initiatives to promote and reduce barriers to screening, and help develop resources focusing on wellness and primary prevention (Lubejko & Wilson, 2019; Yarbro et al., 2018).

 

Warning Signs and Symptoms of Cancer 

Cancer’s presenting signs and symptoms vary depending on the cancer type and its aggressiveness. A patient may be asymptomatic at the time of diagnosis, or signs may be vague and nonspecific, prolonging the time of symptom onset to diagnosis. Some cancers, such as leukemia and lymphoma, can exhibit a cluster of symptoms that imply a malignant process, such as unintentional weight loss, night sweats, lymphadenopathy (enlarged lymph nodes), and fatigue. Ominous signs that should always prompt evaluation include a change in bowel habits; rectal bleeding; vaginal bleeding in postmenopausal women; a firm, fixed, or abnormal lump in the breast; bloody nipple discharge; abdominal bloating or distension that does not resolve within 1-2 weeks; and hemoptysis (coughing blood). While most lung cancers do not cause any symptoms until they have spread, some patients with early lung cancer report persistent coughing that does not improve or gets worse with time, chest pain that is often worse with deep breathing or coughing, shortness of breath, and recurrent infections, such as bronchitis and pneumonia. Cancer may present in many other ways, so a thorough history and a detailed physical assessment are critical (ACS, 2020h; NCI, 2019; Yarbro et al., 2018).

Suspicious warning signs identified on a physical exam can include the following (Nettina, 2019; NCI, 2019; Yarbro et al., 2018):

Oral cavity: white lesions (leukoplakia) or red lesions (erythroplakia), ulcerations, growths, firm or fixed nodules anywhere in the oral cavity

Nasopharynx: nosebleed, permanently blocked nose, sudden hearing loss, enlarged lymph nodes in the upper part of the neck

Larynx: persistent hoarseness of voice without an identifiable cause

Breast: firm, fixed mass or lump in the breast or axilla, new breast asymmetry, nipple retraction, bloody or purulent nipple discharge, skin changes such as an eczematous appearance of the areola, diffuse or localized erythema, retraction, thickening, dimpling resembling an orange peel (peau d’orange), or any open wounds or lesions that arise spontaneously and do not heal

Lung: decreased or absent breath sounds, productive coughing with hemoptysis

Stomach: upper abdominal pain, acute onset of indigestion, unintentional weight loss, swallowing dysfunction

Colon and rectum: change in stool caliber (e.g., thin stools), pain with defecation, incomplete bowel evacuation, unexplained weight loss, anemia, blood in the stool (bright red, maroon, or black-tarry tools)

Skin: brown or dark-colored raised lesion with irregular borders or areas of patchy pink/red that may itch or bleed, keratosis (a lesion or sore on the skin that does not heal)

Bladder: frequent and painful urination, hematuria, incomplete bladder emptying, inability to void, urinary incontinence

Cervix: dyspareunia, post-coital bleeding, abnormal vaginal bleeding, purulent vaginal discharge, easily friable cervix

Prostate: persistent difficulty with urination, frequent nocturnal urination not caused by benign prostatic hypertrophy (BPH) or urinary tract infection (UTI)

Testicular: Swelling of a testicle (asymmetry), lump in the testicle, inguinal lymphadenopathy

 

Cancer Risk Assessment 

A cancer risk assessment is an individualized evaluation of a person’s risk for cancer. The assessment is based on intrinsic and extrinsic factors. It includes a thorough review of past medical, surgical, family, and social history and any age-appropriate screening tests previously performed. Family history includes at least a 3-generation pedigree to evaluate for suspected hereditary cancer syndromes. This information helps identify critical features of familial cancers and genetic syndromes that require heightened surveillance, screening, and prophylactic interventions. Medication history (e.g., hormone replacement therapy [HRT]), dietary history, physical activity, environmental exposures, and tobacco, alcohol, and drug use help complete a cancer risk assessment. Several cancer risk-assessment tools are available to help estimate overall cancer risk and determine interventions to reduce that risk. These tools and based on combinations of risk factors and different datasets. They may be cancer-site specific (e.g., breast cancer) or generalized (e.g., genetic panels) and provide rough estimates. Since each tool uses different factors to estimate risk, they may offer different risk estimates for the same patient, and the estimate can change over time. Healthcare providers use these tools to convey cancer risk information, counsel patients on their risk, and formulate individualized cancer-screening recommendations. A few examples of cancer risk-assessment tools are outlined in Table 1 (ACS, 2022a; Nettina, 2019; NCI, 2022a).

Table 1

Cancer Risk Assessment Tools

Tool	Cancer Type	Description
Gail Model	Breast Cancer	most commonly used comprehensive breast cancer risk assessment tool estimates a woman's 5-year risk and overall lifetime risk for breast cancer
Breast Cancer Risk Assessment Tool (BRISK)	Breast Cancer	estimates a woman’s risk of developing invasive breast cancer over the next 5 years and up to age 90 limitations: cannot accurately estimate the breast cancer risk for women with a mutation in BRCA1 or BRCA2, a history of invasive or in situ breast cancer, or women from other specific subgroups
Colorectal Cancer Risk Assessment Tool (CCRISK)	CRC Cancer	estimates the risk of CRC over the next 5 years and the lifetime risk for males and females who are between 45 and 85 years and White, Black/African American, Asian American/Pacific Islander, or Hispanic/Latino limitations: does not currently apply to American Indians and Alaska Natives or those who are under 45 or older than 85
PREMM5	Hereditary Lynch Syndrome Predictor	clinical prediction algorithm that estimates the probability of carrying a germline mutation among the genes that cause Lynch syndrome, an inherited cancer predisposition (e.g., MLH1, MSH2, MSH6, PMS2, or EPCAM)

(ACS 2022a; Dana-Farber Cancer Institute, n.d.; NCI, n.d.-a; n.d.-b)

The NCI Division of Epidemiology and Genetics (n.d.) offers several online cancer risk assessment tools, most notably for breast and colon cancer. Newer tools are also available for lung cancer risk and the detection of familial cancer syndromes. Many well-established health systems have also generated several online cancer risk assessments for patient use. Johns Hopkins Medicine (n.d.) has created online tools to help patients and healthcare providers assess prostate cancer risk and make treatment decisions. Penn Medicine created a lung cancer assessment tool based on recommendations from the US Preventive Services Task Force (USPSTF) released in 2021. This tool helps determine whether users are eligible for computed tomography (CT) lung cancer screenings; this technique can lead to 20% fewer lung cancer deaths yearly (Penn Medicine, 2021; Smith et al., 2019).

Primary Prevention and Cancer Risk Reduction

Decades of cancer research have identified numerous factors that increase the risk of developing cancer, making primary cancer prevention the most cost-effective long-term strategy for cancer control. Primary cancer prevention consists of interventions implemented before there is evidence of disease. The intent is to reduce or eliminate causative risk factors for cancer development. Since cancers are linked to tobacco use, unhealthy diet and lifestyle behaviors, infections, and viruses, a substantial proportion of cancers can be prevented by minimizing harmful exposures and choosing healthy lifestyle behaviors (ACS, 2022a; American Association for Cancer Research [AACR], 2022a; WHO, 2022b).

Tobacco Use

Tobacco use remains the single most preventable risk factor for cancer mortality worldwide, as all cancer deaths related to tobacco are avoidable. Nearly 34 million US adults smoke cigarettes, and 1,600 people under 18 try their first cigarette daily. Tobacco smoke has more than 7,000 chemicals; at least 70 are known carcinogens. Tobacco harms every organ in the body and is associated with at least 15 types of cancers, including cancer of the lung, mouth, throat, larynx (voice box), esophagus, bladder, kidney, pancreas, cervix, colon, rectum, liver, and stomach. Smoking causes 1 of every 5 deaths in the US. In 2022, approximately 105,840 of the 130,180 lung cancer deaths (81%) will be caused by cigarette smoking. Nearly 58 million non-smokers are exposed to secondhand smoke every year, leading to 7,300 lung cancer deaths annually (ACS, 2020d; Centers for Disease Control and Prevention [CDC], 2022a; Siegel et al., 2022).

All types of tobacco products contain chemicals that are harmful to health. There is no safe form of tobacco. Many tobacco products are on the market, such as e-cigarettes, hookahs, and smokeless tobacco. Many of these contain several of the same chemicals as combustible cigarettes. Using electronic or e-cigarettes is often called vaping. The liquid in e-cigarettes is heated and creates an aerosol of tiny particles inhaled by users. The aerosol consists of harmful chemicals. E-cigarette aerosol can also contain nicotine and other substances that are addictive and can cause cancer, lung disease, and heart disease. Even if e-cigarettes do not contain tobacco, the US Food and Drug Administration (FDA) still classifies them as "tobacco products" due to their risk of severe health effects (ACS, 2020d, 2020g).

 

People who stop smoking experience immediate and long-term health benefits, including reducing their risk of developing lung cancer or experiencing a recurrence. Within 20 minutes after quitting, a person’s heart rate and blood pressure decline. Within a few hours, the level of carbon monoxide in the blood begins to decline. In only a few days, the body's heart rate and blood pressure begin to normalize, and the carbon monoxide level in the bloodstream returns to normal range. Within a few weeks, circulation and lung function improve. One to 12 months after quitting, there is a substantial improvement in lung function with less coughing, wheezing, shortness of breath, and sputum production. The risk of heart attack drops significantly by 2 years, and within 5 to 10 years, the risk of mouth, throat, and larynx cancer is cut in half. After 10 years, the risk of lung cancer drops by at least 50%, and the risk of bladder, esophageal, and kidney cancer declines. At 15 years, a person’s risk of coronary heart disease is nearly the same as that of a non-smoker. Quitting smoking also improves the prognosis of those diagnosed with cancer and can reduce the risk of dying by up to 40% (ACS, 2020e; NCI, 2017).

 

Summary of Recommendations on Tobacco Use and Cancer Prevention

• All tobacco products, including e-cigarettes, pose serious risks and health consequences.
• All healthcare professionals, including nurses, should help patients seek cessation support.
• All adults who smoke conventional cigarettes or combustible tobacco products should be advised to quit smoking immediately and stay tobacco-free.
• E-cigarettes should not be used to quit smoking.
• Medications to assist with smoking cessation can increase the chance of success. There are seven FDA-approved medications to ease the symptoms of nicotine withdrawal. Three nicotine-replacement therapies (NRT) are available over the counter (OTC), including nicotine gum, lozenges, and patches. Four medications are available by prescription: nicotine inhalers, nasal sprays, bupropion (Zyban, an oral antidepressant), and varenicline (Chantix, an oral nicotine-blocker). The ACS recommends oral medications when appropriate, preferably combined with individual or group behavioral counseling, to increase the likelihood of success.
• All 50 states offer free telephone quit lines (e.g., New York State smokers’ Quitline). People who use telephone counseling have twice the success rate in quitting smoking compared with those who do not get this type of support. The ACS offers support in finding local smoking cessation treatment programs by calling 1-800-227-2345.
• The NCI offers a quit-smoking smartphone app that allows users to set quit dates, track progress, and monitor success. (ACS, 2020f; CDC, 2020).

 

Obesity 

Being overweight or obese is associated with an increased risk of at least 13 cancer types, including breast, colon, rectum, endometrial (uterine), esophagus, gallbladder, kidney, and pancreas. Obesity is defined as excess fat accumulation for height and is measured by body mass index (BMI). A person with a BMI of 25.0 to 29.9 is overweight, whereas someone with a BMI of 30 or higher is obese. Excess adipose (fat) tissue can cause metabolic changes that fuel cancer development, such as chronic inflammation, insulin resistance, and higher levels of sex hormones. The risk of cancer increases alongside rising BMI the longer a person remains overweight (ACS, 2020b; CDC, 2022c).

Among all the cancer types, endometrial cancer has the strongest association with obesity, accounting for more than 80% of all endometrial cancers diagnosed worldwide. Formerly a disease of postmenopausal women, endometrial cancer has become more prevalent in the younger, premenopausal population. Since estrogen is carried in adipose tissue, obesity leads to an overproduction of estrogen (hyperestrogenism), increased bioavailability of steroid hormones, and inflammation. These processes fuel a metabolic state that drives tumorigenesis. For those already diagnosed with cancer, obesity leads to poorer long-term health outcomes and negatively impacts the treatment course (Kitson & Crosbie, 2019).

Summary of Recommendations for Obesity and Cancer Prevention

• Achieve and maintain a normal BMI of 18.5 to 24.9 throughout the lifespan.
• Be as lean as possible without being underweight.
• Get regular physical activity and limit the intake of high-calorie foods and drinks.
  • Adults should get at least 150 minutes of moderate-intensity or 75 minutes of vigorous-intensity activity each week (or a combination), preferably spread throughout the week.
  • Children and teens should get at least 1 hour of moderate or vigorous-intensity activity each day, with vigorous activity on at least 3 days each week.
  • Limit sedentary behavior such as sitting, lying down, watching TV, and other forms of screen-based entertainment.
• Eat a healthy diet emphasizing plant foods and calorie and portion control.
• Limit or eliminate the consumption of processed meat and red meat.
• Consume at least 2.5 cups of vegetables and fruits each day.
• Eat whole grains instead of refined products (ACS, 2020b).

 

Alcohol 

Excess alcohol use is the third most important preventable risk factor for cancer, following tobacco use and excess body weight. According to the ACS (2020b), alcohol accounts for approximately 6% of all cancer diagnoses and 4% of cancer deaths in the US.  Alcohol has been linked to mouth, neck, throat, oropharynx, esophagus, liver, colon, rectum, breast, pancreas, and stomach cancers. The more alcohol a person consumes over their lifetime, the higher their risk for cancer becomes. The amount (quantity) of alcohol consumed is essential, not the specific type of alcoholic drink. Alcohol acts as an irritant in the mouth and throat, allowing harmful chemicals like tobacco smoke to enter the cells of the digestive tract. It can lead to inflammation and scarring of the liver, reducing the body's ability to break down harmful chemicals and other exposures. Alcohol reduces the body's ability to absorb certain nutrients, especially folate (folic acid). Folate is a water-soluble B-complex vitamin in food that is essential for red blood cell production and maturation. The human body relies on the dietary intake of folate, which is absorbed within the small intestine and transported to the liver for storage. Many cellular processes in the body require folate to function correctly. Therefore, folate deficiencies significantly contribute to disruptions in cellular development, inducing several sequelae at the cellular level and contributing to cancer (ACS, 2020b; Shulpekova et al., 2021).

Summary of Recommendations for Alcohol and Cancer Prevention

• Men should limit alcohol intake to no more than two drinks per day.
• Women should limit alcohol intake to one drink per day.

• One drink of alcohol is defined as any of the following:
  • 12 ounces of beer
  • 5 ounces of wine
  • 1.5 ounces of 80-proof distilled spirits (i.e., hard liquor)

People who should avoid alcohol include:

• children and teens
• those of any age who cannot limit their drinking
• people with a family history of alcoholism
• pregnant women or women who may become pregnant
• those who drive or operate machinery or partake in other activities that require attention, skill, and coordination
• people taking any medications (prescription or OTC) that interact with alcohol (ACS, 2020b)

UV Exposure

People frequently exposed to UV rays are at a higher risk for skin cancer, as skin cancers are primarily due to excessive UV radiation exposure. UV radiation is part of the natural energy produced by the sun's invisible rays but is also made from artificial sun lamps and tanning beds. UV radiation can damage the skin and lead to skin cancer. Long-wave ultraviolet A (UVA) and short-wave ultraviolet B (UVB) rays reach the Earth's surface and contribute to skin cancer. While UVA and UVB rays differ in how they affect the skin, they both cause harm; when combined, the risk for damage rises. Unprotected exposure to UVA and UVB rays damages the DNA in skin cells, producing genetic defects (mutations) that can lead to premature aging, wrinkles, skin cancer, and immune system suppression. The more prolonged and intense the UV exposure is, the greater the consequences to the skin (Curiel-Lewandrowski, 2022; Gruber & Zito, 2022).

The sun's UV rays can damage unprotected skin in as little as 15 minutes, yet it can take up to 12 hours for skin to show the full effect of sun exposure. A tan is the body's attempt to protect itself from harm, even without a sunburn. Sunburns and suntans are signs that skin has been damaged. The more damage the sun does to the skin, the more likely the individual will develop complications. UV radiation can penetrate light clothing, windows, and windshields. It is also reflected by sand, water, snow, and concrete. It can reach swimmers at least one foot beneath the water's surface. Roughly 60% to 80% of the sun's rays transmit through clouds, so clouds and water do not offer protection (Curiel-Lewandrowski, 2022; Gruber & Zito, 2022; Saric-Bosanac et al., 2019).

While most UV exposure comes from the sun, it can also come from indoor tanning beds and sun lamps. Skin prevention strategies focus on applying proper sunscreen, lightweight clothing, and hats to shield against direct exposure, reducing sunlight during peak hours when the UV rays are the strongest, and avoiding tanning beds altogether. The best way to detect skin cancer early is to be aware of new or changing skin growths, particularly those that look unusual. A skin cancer diagnosis is usually suspected for older, fair-skinned patients who present with scaly, indurated lesions on sun-exposed areas of the head and neck. Specific risk factors associated with increased environmental or artificial UV exposure include the following:

• long-term, intense sun exposure without adequate use of sunblock and other sun safety precautions
• Northern European ethnic origin
• people with fair skin, blonde or red hair, and light-colored eyes
• a tendency to burn rather than tan
• living within closer proximity to the equator
• history of blistering sunburns in childhood and adolescence
• use of indoor tanning beds
• people with a weakened immune system, including organ transplantation recipients
• exposure to therapeutic ionizing radiation
• HIV seropositivity
• specific genetic syndromes (ACS, 2019a, 2019b; Curiel-Lewandrowski, 2022; Gruber & Zito, 2022)

While many researchers and clinicians argue that skin cancer screening with a full-body skin examination is among the safest, most practical, and cost-effective medical screening tests, there currently remains no national consensus regarding its benefit or implementation. Although the US Preventive Services Task Force (USPSTF, 2018) concluded that the current evidence is insufficient regarding self-examination to prevent skin cancer, many organizations—including the American Academy of Dermatology (AAD, n.d.), the ACS (2019a, 2019b), and the Melanoma Research Alliance (n.d.)—jointly emphasize the importance of monthly skin self-examinations. These organizations advise healthcare professionals to counsel patients on performing skin self-examinations in a well-lit room during daylight hours, preferably once a month. Patients should also be given access to a body map diagram or encouraged to use a skin mole-tracking mobile device application to note any areas of suspicion. HCPs should teach patients the following steps for performing a skin self-exam:

• examine the body in a full-length mirror
• examine the underarms, forearms, and palms
• examine the legs and soles of the feet, then between the toes
• use a hand mirror to examine the scalp and neck
• use a hand mirror to examine the buttocks and back (AAD, n.d.)

Summary of Recommendations on UV Exposure and Cancer Prevention

• Perform monthly skin self-examinations to detect early skin cancer.
• Any new lesion or a progressive change in a lesion's appearance (size, shape, or color change) should be evaluated promptly by a clinician.
• Take steps to limit exposure to UV rays:
  • Seek shade and limit direct sunlight exposure, especially between 10 a.m. and 4 p.m. when UV light is the strongest.
  • Implement the catchphrase, "Slip, slop, slap, and wrap!" (i.e., slip on a shirt, slop on sunscreen, slap on a hat, and wrap on sunglasses).
    • Long-sleeved shirts, long pants, and/or long skirts cover the most skin and are the most protective. Dark-colored clothing provides more protection than light-colored clothing.
    • Choose a sunscreen with broad-spectrum protection against UVA and UVB rays and a sun protection factor (SPF) value of 30 or higher.
    • No sunscreen provides 100% protection.
    • Wear a hat with at least a 2- to 3-inch brim to shield the sun.
    • Wear UV-blocking sunglasses to protect the eyes and the surrounding skin.
• Avoid tanning beds and sun lamps (ACS, 2019b).

 

Refer to the Skin Cancer and Prevention Nursing CE course for more information on this topic.

 

Human Papillomavirus (HPV)

HPV is a common virus that can cause cancers of the cervix, vagina, vulva, penis, anus, and oropharynx. All HPV-related cancers can be prevented through behavioral and lifestyle changes and vaccination. Approximately 80% of people (8 out of 10) will get an HPV infection in their lifetime. HPV causes nearly all cervical cancers, and more than 35,000 people in the US are diagnosed with cancers caused by HPV annually. The FDA-approved HPV vaccination Gardasil9 can protect against over 90% of HPV cancers, precancers, and genital warts when given at the recommended ages. The HPV vaccination series is most effective when administered to children aged 12 and younger before contact with the virus (ACS, 2020c; CDC, 2022b).

Summary of Recommendations on HPV Vaccination and Cancer Prevention

• Children between 9 and 12 should receive two doses of the HPV vaccine.
• Teens and young adults aged 13 through 26 who have not been vaccinated or who have not received both doses should get the vaccine as soon as possible. Vaccination of young adults will not prevent as many cancers as vaccination of children and teens.
• The ACS does not recommend HPV vaccination for persons older than age 26 years (ACS, 2020c)

Refer to the Human Papillomavirus (HPV) NursingCE course for more information on this topic. 

 

Secondary Cancer Prevention

Secondary cancer prevention consists of interventions implemented after a disease has begun but before symptoms present (i.e., in asymptomatic disease). Secondary prevention intends to identify cancer early in its development to reduce morbidity and mortality and improve outcomes. Premised on the biological and clinical understanding that a long incubation period is required for developing malignant tumors, screening is recommended when there is substantial evidence that the early diagnosis and treatment of asymptomatic disease will reduce mortality or disease severity. The sooner a cancer is detected, the more effective the treatment will be. Developments in early detection and screening practices have generated highly specialized techniques that can identify tissue changes, cancer precursors, and early-stage tumors. Early detection dramatically increases the chances of successful treatment and the potential for a cure. Millions of cancer patients could be saved from premature death and suffering if they had timely access to early detection and treatment. Examples of cancer screening tests include colonoscopy, sigmoidoscopy, fecal occult blood testing (FOBT), mammography, Papanicolaou testing (Pap smear), prostate-specific antigen (PSA), and digital rectal examination (DRE; AACR, 2022b; Loomans-Kropp & Umar, 2019; NCI, 2022b; Yarbro et al., 2018).

As with all medical interventions, screening does confer some risks. Nurses must ensure that patients are fully informed and understand the benefits and risks of cancer screening and their odds of developing cancer. The decision to perform routine screening tests should be based on whether the test is (a) adequate to detect a potentially curable cancer in an otherwise-asymptomatic person and (b) cost-effective. Screening decisions should be based on an individual's age, sex, family history of cancer, ethnic group or race, previous iatrogenic factors (prior radiation therapy), and history of environmental carcinogens. In cases of diagnosed cancer, continued surveillance and screening remain essential for the early detection of new and recurrent cancers (AACR, 2022b; Loomans-Kropp & Umar, 2019; NCI, 2022b; Yarbro et al., 2018).

 

Cancer Screening Guidelines

Various cancer screening guidelines have been generated by credible organizations and are grounded in clinical research evidence and expert consensus. While there are some variations, the guidelines are relatively consistent in their recommendations. The ACS is one of the most widely utilized, comprehensive, evidence-based resources for cancer care. The ACS publishes an annual report that summarizes recommendations for cancer screening, which will be discussed in this section (ACS, 2022a; Smith et al., 2019).

Breast Cancer

Aside from skin cancers, breast cancer is the most common cancer type among women in the US and accounts for 1 in 3 new female breast cancer diagnoses each year. The ACS estimates that in 2022, there will be 287,850 new cases of invasive breast cancer and about 43,250 deaths. Breast cancer is the second leading cause of cancer deaths in women. There will also be approximately 51,400 cases of ductal carcinoma in situ (DCIS), a noninvasive or pre-invasive breast cancer. The lifetime risk of breast cancer for average women is about 13%, reflecting a 1 in 8 chance of developing breast cancer. Over the last few years, the incidence rate has increased by approximately 0.5% per year, but breast cancer death rates have steadily declined. Breast cancers identified during screening exams are more likely to be small and confined to the breast. The size of cancer and the extent of its spread are some of the most critical factors in predicting a patient’s prognosis, as the size of cancer at the time of diagnosis is directly related to mortality. Breast cancer screening is commonly performed through mammography and a breast x-ray. Screening mammograms can detect cancers before they grow large enough to become palpable lumps. Dense breast tissue is an independent risk factor for developing breast cancer, with a relative risk that is 2 to 6 times higher than that for less-dense breasts. Starting screening mammography at age 40 saves the most lives, and annual screening saves more lives than biennial (every other year) screening (ACS, 2022a, 2022b, 2022c).

Annual mammography screening of premenopausal women is associated with a significantly decreased risk of identifying advanced breast cancer compared with screening performed every other year. Postmenopausal women do not have similar benefits related to yearly screening unless they currently receive hormone treatment for menopause.  Therefore, women 55 years or older can receive screening every other year or yearly, depending on patient preference. The age to stop screening has not been identified. However, continued screening may benefit certain women 75 years or older, depending on their mortality risk, comorbidities, overall health, and performance status. Patients should be advised not to schedule their mammogram the week before or during their menstrual cycle, as the breasts may be more tender and swollen at this time. Patients should also be instructed on avoiding deodorants, perfumes, or powders prior to the procedure. All women should be counseled on the benefits, limitations, and potential harms associated with breast cancer screening before undergoing any breast cancer screening test. Women should regularly check their breasts to know how they usually look and feel and promptly report any breast changes to a healthcare provider (ACS, 2022a, 2022b; Smith et al., 2019).

Summary of Breast Cancer Screening Recommendations

Average-Risk Women. Nurses can advise women in this group as follows (ACS, 2022a, 2022b):

• Women aged 40 to 44 should have the opportunity to begin annual screening with mammography if they choose to do so.
• Women aged 45 to 54 should undergo annual mammography.
• Women aged 55 and older should transition to biennial screening (screening every 2 years) or continue screening annually if they wish to do so.
• Women should continue screening mammography if their overall health status is good and they have a life expectancy of at least 10 years.

 

High-Risk Women. Women at high risk for breast cancer due to family history, a genetic predisposition, or certain other factors should be screened with magnetic resonance imaging (MRI) and mammograms, typically starting at age 30 and continuing for as long as they are in good health. This applies to women with any of the following:

• a lifetime risk of breast cancer of 20% or more, according to validated breast cancer risk assessment tools
• a known BRCA1 or BRCA2 gene mutation
• a first-degree relative (e.g., parent, sibling, or child) with a BRCA1 or BRCA2 gene mutation and no prior genetic testing
• prior radiation therapy to the chest (e.g., for Hodgkin’s disease) administered between the ages of 10 and 30 years
• Li-Fraumeni syndrome, Cowden syndrome, Bannayan-Riley-Ruvalcaba syndrome, or a first-degree relative with any of these syndromes (ACS, 2022a, 2022b; Smith et al., 2019)

Women who are known or likely carriers of a breast cancer gene (BRCA) mutation and other rare high‐risk genetic syndromes are considered at increased risk. Annual screening mammography and MRI starting at age 30 years are recommended for women with a known BRCA mutation, women who are untested but have a first‐degree relative with a BRCA mutation, or women with an approximately 20% or greater lifetime risk of breast cancer based on validated breast cancer risk‐estimation tools. Annual MRI and mammography are also recommended for women who received radiation therapy to the chest between the ages of 10 and 30 (ACS, 2022a, 2022b; Smith et al., 2019).

Lung Cancer

Lung cancer is the second most common cancer affecting men and women and is the leading cause of cancer-related deaths. The ACS estimates there will be approximately 236,720 new cases of lung cancer and 130,180 deaths in 2022. Lung cancer primarily affects people aged 65 and older. However, the number of new lung cancer diagnoses has declined over recent years as more people stop smoking. Advancements in early detection and treatment have also led to fewer deaths. Risk factors for lung cancer include tobacco use, secondhand smoke, and harmful chemical or radioactive exposures. More than 350 people die each day from lung cancer, which is more than breast, prostate, and pancreatic cancers combined (Siegel et al., 2022).

Radon is a radioactive gas produced by the breakdown of uranium in soil and rocks. It is an odorless and tasteless gas and is the second leading cause of lung cancer in the US and the leading cause among non-smokers. Additional carcinogens that can increase lung cancer risk include diesel exhaust, asbestos, and inhaled chemicals such as arsenic, beryllium, cadmium, silica, vinyl chloride, nickel compounds, chromium compounds, coal products, mustard gas, and chloromethyl ethers. Prior radiation therapy to the chest for other cancers also increases the risk of lung cancer development. This is common in breast cancer patients, as many receive chest wall radiation following a mastectomy (ACS, 2022f).

Summary of Lung Cancer Screening Recommendations

People who currently or formerly smoked are at increased risk for lung cancer. For some people, the ACS recommends annual lung cancer screening with a low-dose CT scan (LDCT). Since the most recent version of the ACS lung cancer screening guideline published in 2018 is undergoing an update, the ACS recommends that healthcare providers and patients follow the updated USPSTF (2021) recommendations for lung cancer screening. According to the USPSTF (2021), annual lung cancer screening with LDCT is recommended for adults aged 50 to 80 and in good health who currently smoke or have quit in the past 15 years and have at least a 20-pack-year smoking history (see Box 1). This updated recommendation will almost double the number of people eligible for screening and potentially save more lives than the previous guidelines.

             In addition, the USPSTF (2021) recommends that people who undergo screening also:

• receive smoking cessation counseling if they are current smokers, and
• are informed about the potential benefits, limitations, and harms of screening with LDCT scans, and
• have access to a high-volume, high-quality lung cancer screening and treatment center

Screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability to undergo curative lung surgery.  Smoking cessation counseling is of utmost importance for current smokers, who should be informed of their ongoing risk of lung cancer and adverse health outcomes with continued smoking. Screening should not be viewed as an alternative to smoking cessation. All current smokers should be assessed for readiness to quit and referred to smoking cessation programs (ACS, 2022h; USPSTF, 2021).

Box 1

Calculating Smoking Pack-Years

A pack-year is defined as one pack of cigarettes per day per year. This is the number of packs of cigarettes each day multiplied by the number of years smoked. For example, a person who smoked three packs a day for 10 years (3 x 10 = 30) has 30 pack-years of smoking. Furthermore, a person who smoked one pack of cigarettes per day for 30 years or two packs per day for 15 years would also be 30 pack-years.

 (ACS, 2022h; Smith et al., 2019)

Colorectal Cancer (CRC)

Excluding skin cancers, CRC is the third most common cancer diagnosed among adults and the third leading cause of cancer-related deaths in the US. The lifetime risk of developing CRC is about 1 in 23 (4.3%) for males and 1 in 25 (4%) for females. The ACS estimates there will be 151,030 new cases and 52,580 deaths from CRC in 2022. The death rate has declined for several years due to increased screening, early detection, and improved treatment. There are currently more than 1.5 million CRC survivors in the US. CRC screening can detect precancerous and cancerous tumors early when they are small, localized, and easier to treat. When CRC is found at an early stage before it has spread, the 5-year relative survival rate is 91%. Regular screenings at defined intervals can prevent CRC from developing, as a cancerous polyp can take 10 to 15 years to progress into cancer. Screening allows for the prevention of CRC by removing abnormal, suspicious, or precancerous polyps before they can develop into cancer (ACS, 2022e).  

The ACS guideline for colorectal cancer screening was last updated in 2018 and recommends that average-risk adults aged 45 years and older should undergo regular screening with either a high-sensitivity stool-based test or a structural (visual) exam (e.g., colonoscopy) based on personal preferences and test availability. All positive results on non-colonoscopy screening tests should be followed with a timely colonoscopy (Wolf et al., 2018).

Average Risk for CRC. 

• Start CRC screening at 45 years using high-sensitivity fecal testing or visual examination.
• CRC screening after age 75 should be individualized based on patient preference, life expectancy, health, screening history, and risk of adverse events.
• Screening should be discouraged for patients older than 85 due to an increased risk of screening complications and mortality.

Although limited evidence exists on the outcomes of screening average-risk adults aged 45 through 49, the ACS recommendation is based on increased CRC incidence at young ages and observational studies that screening tests would generate similar outcomes in this population (Wolf et al., 2018).

 

Increased or High-Risk for CRC. Those at an increased or high risk of CRC should start screening before age 45. These people often require more frequent screening and specific testing types. The ACS (2020a) defines high-risk to include those who have one or more of the following:

• personal history of CRC or certain types of polyps
• family history of CRC
• personal history of inflammatory bowel disease (e.g., ulcerative colitis or Crohn’s disease)
• confirmed or suspected hereditary CRC syndromes, such as familial adenomatous polyposis (FAP) or Lynch syndrome (hereditary non-polyposis colon cancer [HNPCC])
• personal history of radiation to the abdominal or pelvic region

The absence of these risk factors defines individuals at average risk for CRC. The guidelines for those at increased risk for CRC vary based on each patient and their findings on screening tests. While the ACS does not set screening guidelines specifically for people in higher-risk categories, other professional organizations like the USPSTF and the American Society of Clinical Oncology (ASCO) offer more complex guidelines that must be applied to each patient based on individual risk factors (ACS, 2020a).

 

Screening Modalities for CRC. There are multiple options for CRC screening, all of which are associated with a significant reduction in CRC incidence through the early detection and removal of adenomatous polyps and precancerous lesions. There are several test options for CRC screening, which include:

• Stool-based tests:
  • fecal immunochemical test (FIT) performed every year
  • high‐sensitivity guaiac‐based fecal occult blood test (HSgFOBT) performed every year
  • multitarget stool DNA test (mt‐sDNA), performed every 3 years
• Visual (structural) exams of the colon and rectum
  • colonoscopy performed every 10 years
  • computed tomography colonography (virtual colonoscopy) performed every 5 years
  • flexible sigmoidoscopy (FSIG) performed every 5 years (Smith et al., 2019; Wolf et al., 2018)

Summary of Colorectal Cancer Screening Recommendations

             Note the following recommendations for CRC testing (Wolf et al., 2018):

• Average-risk adults aged 45 years and older should undergo regular CRC screening with either a high-sensitivity stool-based test or a visual exam, based on patient preference and test availability.
• Average‐risk adults in good health with a life expectancy of more than 10 years should continue CRC screening through 75 years.
• Clinicians should individualize CRC screening decisions for individuals aged 76 through 85 based on patient preferences, life expectancy, overall health and performance status, and prior screening history.
• Clinicians should discourage individuals older than 85 years from continuing CRC screening.
• All positive results on non-colonoscopy screening tests must be followed with a timely colonoscopy.

Cervical Cancer

Cervical cancer is most frequently diagnosed in women between 35 and 44 years. It rarely develops in women younger than 20, and more than 20% of cases of cervical cancer are found in women over 65. In 2022, nearly 200,000 women will be diagnosed with a cervical precancer, 14,100 will be diagnosed with invasive cervical cancer, and 4,280 women will die from the disease. More than 9 of 10 cervical cancers are caused by HPV and can be prevented by HPV vaccination. Cervical cancer screening with high‐quality cytology (i.e., Pap testing) has reduced cervical cancer incidence and mortality by detecting cervical precancers. Cervical cancer was among the most common causes of cancer-related deaths for women in the US. HPV vaccination and screening have made cervical cancer a highly preventable cancer. Pap testing has markedly reduced mortality from cervical cancer by detecting precancerous changes in the cervix before cancer develops. More recently, the HPV test has been approved as another screening test for cervical cancer. The HPV test looks for infection with high-risk subtypes of HPV that are more likely to cause cervical precancer and invasive cancer. HPV testing can be performed alone (i.e., primary HPV test) or simultaneously with the Pap test (i.e., co-test). The ACS notes that the most important thing is for patients to get screened regularly, regardless of which test they use (ACS, 2021a, 2022d; CDC, 2022b; Smith et al., 2019).

Summary of Cervical Cancer Screening Recommendations

Recommendations for cervical cancer prevention are as follows (ACS, 2021a, 2022d):

Cervical cancer screening should begin at age 25. Women under 25 years should not be screened, regardless of the age of sexual initiation.

• Women aged 25 to 65 should have a primary HPV test every 5 years. If primary HPV testing is unavailable, screening may be performed with either a co-test that combines an HPV test with a Pap test every 5 years or a Pap test only every 3 years.
• Women older than 65 who have had regular screenings in the past 10 years with normal results and no history of CIN2 or more severe diagnosis within the past 25 years should stop cervical cancer screening. Once stopped, screening should not be resumed.
• Women who have undergone a total hysterectomy (i.e., removal of the uterus and cervix) should discontinue screening Pap tests and HPV tests unless the hysterectomy was performed for the treatment of cervical cancer or precancer.
• People who have undergone a hysterectomy without removal of the cervix (i.e., supra-cervical hysterectomy) should continue cervical cancer screening according to the guidelines outlined above.
• People who have been vaccinated against HPV should still follow these guidelines for their age groups.

Prostate Cancer

Other than skin cancer, prostate cancer is the most common cancer diagnosed in men in the US, with an estimated 268,490 new cases and 34,500 deaths in 2022. The lifetime risk of prostate cancer is about 1 in 8 and most commonly affects older, non-Hispanic Black men. Nearly 6 in 10 cases are diagnosed in men aged 65 and older. Despite its high incidence, most men with prostate cancer do not die from it. There are currently over 3.1 million prostate cancer survivors in the US (ACS, 2022g). There has been an ongoing controversy over prostate cancer screening risks and benefits for decades. Two modalities are used for prostate cancer screening, prostate‐specific antigen testing (PSA) and digital rectal examination (DRE). Prostate cancer screening may be associated with reduced mortality from prostate cancer, but the evidence remains conflicting, as experts disagree about the value of screening. The major shortcoming of prostate cancer screening is the impact and value of the information received. Providers cannot predict which men will benefit from treatment when prostate cancer is diagnosed through screening. Some men may avoid death and disability from prostate cancer, but many will die from unrelated causes. There is an extensive literature base on the potential overtreatment and overdiagnosis of prostate cancer due to PSA screenings (ACS, 2021b; Kappen et al., 2019; Siegel et al., 2022; Smith et al., 2019).

Currently, the ACS advises that prostate cancer screening should not occur without an informed decision-making process between healthcare providers and each patient, reviewing the pros and cons of screening. Men with at least a 10-year life expectancy should have the opportunity to make an informed decision about undergoing prostate cancer screening with serum PSA, with or without DRE. Men who fall into higher risk categories include African Americans and those with a first-degree family member (e.g., father or brother) diagnosed with prostate cancer before age 65. Additional factors that increase prostate cancer risk consist of age, abnormal DRE, and high age-specific PSA level tests. Research is not yet clear on the value and best use of the PSA and DRE (ACS, 2021b; Smith et al., 2019).

Summary of Prostate Cancer Screening Recommendations

• At age 50, average-risk men should have an informed/shared decision-making conversation with their healthcare provider about the pros and cons of prostate cancer screening.
• African Americans and men who have a first-degree relative who was diagnosed with prostate cancer before age 65 are at higher risk and should have this informed/shared decision-making conversation starting at age 45.
• Men at the highest risk (those with multiple first-degree relatives diagnosed with prostate cancer before age 65) should receive this information at age 40.
• Asymptomatic men with below a 10-year life expectancy based on age and health status should not be offered prostate cancer screening.
• For those who opt for testing, the ACS recommends the following:
  • Men aged 50 and older may decide to undergo PSA testing with or without DRE (DRE is recommended along with PSA for men with hypogonadism because of the reduced sensitivity of PSA).
  • The frequency of PSA testing frequency depends on the results and patient and provider preferences.
    • PSA below 2.5 ng/mL: screening intervals can be extended to every 2 years
    • PSA above 2.5 ng/mL: screening should be performed annually

 

Endometrial Cancer

In 2022, the ACS estimates that 65,950 women will be diagnosed with and 12,550 women will die from endometrial (uterine) cancer. In 2001, the ACS concluded that there was insufficient evidence to recommend screening for endometrial cancer among women at average risk, and their assessment remains unchanged today. The ACS recommends that at the time of menopause, women should be informed about the risks and symptoms of endometrial cancer and strongly encouraged to report any unexpected vaginal bleeding or spotting to their healthcare provider. Endometrial biopsy is the standard for evaluating any suspected pathology involving the endometrium but is only advised if there are clinical signs or symptoms raising concern for disease (Siegel et al., 2022; Smith et al., 2019).

 

Risks and Limitations of Cancer Screening

Despite the notable benefits of cancer screening, no screening test is perfect, as they all confer some risks and limitations. While there have been tremendous advancements in early detection and screening processes, published guidelines and screening recommendations are unavailable for all cancer types. For example, ovarian cancer is one of the deadliest cancers, yet no organization recommends routine screening for ovarian cancer among average‐risk women. Under one-half of women diagnosed with ovarian cancer survive longer than 5 years, and under 20% of all patients are diagnosed with localized disease. Screening and diagnostic methods for ovarian cancer include pelvic examination, cancer antigen-125 (CA-125) blood level tumor marker, and transvaginal ultrasound (TVUS). Due to limitations in ovarian cancer screening modalities and a lack of evidence to suggest the benefit of screening average-risk women, these modalities are generally reserved for women of higher risk, such as those with a hereditary genetic predisposition or strong family history (Siegel et al., 2022; Smith et al., 2019).

Nurses must engage in informed and shared decision-making with patients regarding the benefits and limitations of cancer screening modalities. These discussions help patients clarify their values and decide if they are willing to accept the risks and costs associated with screening. All types of cancer screening pose a relatively high likelihood of the need for further tests. Some tests have higher risks for complications, whereas others are safer and pose fewer risks. Regardless of a patient's preference, nurses are responsible for ensuring each patient is educated on the risk-benefit ratio to make an informed decision (Yarbro et al., 2018).

The most common risks of cancer screening include false-positive test results, false-negative test results, overdiagnosis, and overtreatment. Detecting cancer does not always improve a patient's health or survival. Screening can also lead to overdiagnosis and overtreatment. The widespread use of mammography and prostate cancer screening are primary examples of the potential harms stemming from the detection of indolent lesions and subsequent overtreatment, which contributes to unnecessary healthcare spending and provokes patient anxiety. False-negative test results are a limitation of cancer screening in which the screening test fails to detect cancer. LDCT scans do not detect all lung cancers, and not all patients who have lung cancer detected by LDCT will avoid death from lung cancer. Mammograms may miss some cancers, which can delay finding cancer and getting treatment (ACS, 2022a; Smith et al., 2019; Yarbro et al., 2018).

False-positive test results occur when something found on screening looks like cancer but is benign. This can lead to the need for additional testing, which can be expensive, invasive, time-consuming, and may stimulate additional anxiety. In some instances, an invasive procedure is needed to determine whether an abnormality is cancer or some non‐cancerous or non‐related incidental finding. Any invasive procedure poses the risk of minor and major complications. Testing can lead to overdiagnosis, which occurs when a cancer is found that would not have caused symptoms or may have resolved on its own. Routine PSA screening has led to the overdiagnosis and, in turn, overtreatment of many indolent prostate cancers. Overtreatment refers to treatments administered due to the identification of cancer that may not have ever been necessary. These cases can cause adverse effects and add unnecessary healthcare expenses (ACS, 2022a; Kappen et al., 2019; Loomans-Kropp & Umar, 2019; Smith et al., 2019; Yarbro et al., 2018).

 

Barriers to Cancer Screening

There are numerous barriers to cancer screening. Some of the most common barriers include the following:

• socioeconomic status and demographics, including income, age, and marital status
• accessibility to healthcare providers, healthcare services, and screening facilities
• insurance coverage and insurance type, including high out-of-pocket costs of care (deductibles, copays, coinsurance)
• transportation and travel time
• psychosocial issues (e.g., anxiety and fear of a screening procedure, pain, and possible results)
• forgetfulness
• lack of motivation
• lack of knowledge or understanding
• health behaviors (e.g., current smokers are less likely to undergo cancer screenings)
• COVID-19: the pandemic delayed many elective procedures for an extended time, leading to a substantial decline in cancer screening; over the last year, many healthcare facilities have resumed cancer screenings with added safety precautions, but patients’ willingness to return to screening remains questionable (ACS, 2021c; Jang et al., 2019; Loomans-Kropp & Umar, 2019)

Regular cancer screening is critical. Early detection offers the best chance of finding cancer when it is most treatable. Prevention and early detection are the best and most effective treatments for cancer, as they result in decreased morbidity and mortality. Developing risk profiles and screening guidelines enhances screening efficacy and reduces healthcare costs and unnecessary spending. Table 2 summarizes the key teaching points for cancer prevention and early detection that nurses can share with patients (AACR, 2022b; NCI, 2022b; Smith et al., 2019).

 

Table 2

Key Patient Teaching Points: Cancer Prevention and Early Detection 

Stop smoking	There is no safe form of tobacco. Smoking is the most preventable cause of cancer-related death in the US. Smoking cessation counseling should include all forms of tobacco, vaping, and other illicit drugs.
Limit alcohol intake	Females should limit alcohol intake to one drink per day, and males should have no more than two drinks per day.
Maintain a healthy weight through diet and exercise	Diet: Consume a diet high in vegetables, fiber, whole grains, and other nutrients to support a healthy weight. Limit or eliminate red and processed meats and sugar-sweetened beverages and reduce consumption of salt, processed foods, and high-fat, greasy foods.
	Exercise: Adults should engage in 150 to 300 minutes of moderate-intensity or 75 to 150 minutes of vigorous-intensity physical activity throughout the week. Achieving or exceeding 300 minutes of moderate-to-vigorous exercise weekly is ideal. Limit time spent sedentary and sitting.
Practice sun safety	Avoid sun exposure, especially between 10 a.m. and 4 p.m., and cover exposed skin with sunscreen with a skin protection factor of 30 or higher.
Avoid tanning beds	There is no such thing as a safe tanning bed.
Get vaccinated against HPV	HPV causes most cervical, vulvar, vaginal, anal, oropharyngeal, and penile cancers. HPV vaccination is recommended for all children aged 9 to 12, up to 26 years. The vaccine is the most effective at younger ages before contact with the virus.
Get screened	Females should be screened for cervical, breast, and colorectal cancers. Males should be screened for prostate and colorectal cancers. Patients at higher risk should be referred to counselors for genetic testing (if advised) and educated on the importance of increased cancer screening intervals and risk-reduction strategies as appropriate.

(AACR, 2020b; 2022b; NCI, 2022b; Smith et al., 2019)

References

American Academy of Dermatology. (n.d.). Detect skin cancer: How to check your skin. Retrieved October 30, 2022, from https://www.aad.org/skin-cancer-find-check

American Association for Cancer Research. (2022a). Preventing cancer: Identifying risk factors. https://cancerprogressreport.aacr.org/progress/cpr22-contents/cpr22-preventing-cancer-identifying-risk-factors

American Association for Cancer Research. (2022b). Screening for early detection. https://cancerprogressreport.aacr.org/progress/cpr22-contents/cpr22-screening-for-early-detection

American Cancer Society. (2019a). How do I protect myself from ultraviolet (UV) rays? https://www.cancer.org/healthy/be-safe-in-sun/uv-protection.html

American Cancer Society. (2019b). Ultraviolet (UV) radiation. https://www.cancer.org/healthy/cancer-causes/radiation-exposure/uv-radiation.html

American Cancer Society. (2020a). American Cancer Society guideline for colorectal cancer screening. https://www.cancer.org/cancer/colon-rectal-cancer/detection-diagnosis-staging/acs-recommendations.html

American Cancer Society. (2020b). American Cancer Society guideline for diet and physical activity. https://www.cancer.org/healthy/eat-healthy-get-active/acs-guidelines-nutrition-physical-activity-cancer-prevention/guidelines.html

American Cancer Society. (2020c). American Cancer Society recommendation for human papillomavirus (HPV) vaccine use. http://www.cancer.org/cancer/cancer-causes/infectious-agents/hpv/acs-recommendations-for-hpv-vaccine-use.html

American Cancer Society. (2020d). Harmful chemicals in tobacco products. https://www.cancer.org/healthy/cancer-causes/tobacco-and-cancer/carcinogens-found-in-tobacco-products.html

American Cancer Society. (2020e). Health benefits of quitting smoking over time. https://www.cancer.org/healthy/stay-away-from-tobacco/benefits-of-quitting-smoking-over-time.html

American Cancer Society. (2020f). How to quit smoking. https://www.cancer.org/latest-news/how-to-quit-smoking.html

American Cancer Society. (2020g). Is any type of tobacco product safe? https://www.cancer.org/healthy/cancer-causes/tobacco-and-cancer/is-any-type-of-smoking-safe.html

American Cancer Society. (2020h). Signs and symptoms of cancer. https://www.cancer.org/treatment/understanding-your-diagnosis/signs-and-symptoms-of-cancer.html

American Cancer Society. (2021a). The American Cancer Society guidelines for the prevention and early detection of cervical cancer. https://www.cancer.org/cancer/cervical-cancer/detection-diagnosis-staging/cervical-cancer-screening-guidelines.html

American Cancer Society. (2021b). American Cancer Society recommendations for prostate cancer early detection. https://www.cancer.org/cancer/prostate-cancer/detection-diagnosis-staging/acs-recommendations.html

American Cancer Society. (2021c). Cancer screening during the COVID-19 pandemic. https://www.cancer.org/healthy/find-cancer-early/cancer-screening-during-covid-19-pandemic.html

American Cancer Society. (2022a). American Cancer Society guidelines for the early detection of cancer. https://www.cancer.org/healthy/find-cancer-early/american-cancer-society-guidelines-for-the-early-detection-of-cancer.html

American Cancer Society. (2022b). American Cancer Society recommendations for the early detection of breast cancer. https://www.cancer.org/cancer/breast-cancer/screening-tests-and-early-detection/american-cancer-society-recommendations-for-the-early-detection-of-breast-cancer.html

American Cancer Society. (2022c). Key statistics for breast cancer. https://www.cancer.org/cancer/breast-cancer/about/how-common-is-breast-cancer.html

American Cancer Society. (2022d). Key statistics for cervical cancer. https://www.cancer.org/cancer/cervical-cancer/about/key-statistics.html

American Cancer Society. (2022e). Key statistics for colorectal cancer. https://www.cancer.org/cancer/colon-rectal-cancer/about/key-statistics.html

American Cancer Society. (2022f). Key statistics for lung cancer. https://www.cancer.org/cancer/lung-cancer/about/key-statistics.html

American Cancer Society. (2022g). Key Statistics for prostate cancer. https://www.cancer.org/cancer/prostate-cancer/about/key-statistics.html

American Cancer Society. (2022h). Lung cancer screening guidelines. https://www.cancer.org/health-care-professionals/american-cancer-society-prevention-early-detection-guidelines/lung-cancer-screening-guidelines.html

Centers for Disease Control and Prevention. (2020). Smoking cessation – The role of healthcare professionals and health systems. https://www.cdc.gov/tobacco/data_statistics/sgr/2020-smoking-cessation/fact-sheets/healthcare-professionals-health-systems/index.html

Centers for Disease Control and Prevention. (2022a). Cancer. https://www.cdc.gov/chronicdisease/resources/publications/factsheets/cancer.htm

Centers for Disease Control and Prevention. (2022b). HPV Cancers. https://www.cdc.gov/hpv/parents/cancer.html

Centers for Disease Control and Prevention. (2022c). Obesity and cancer. https://www.cdc.gov/cancer/obesity/index.htm

Curiel-Lewandrowski, C. (2022). Risk factors for the development of melanoma. UpToDate. Retrieved October 30, 2022, from https://www.uptodate.com/contents/risk-factors-for-the-development-of-melanoma

Dana-Farber Cancer Institute. (n.d.). Lynch syndrome prediction model. Retrieved October 28, 2022, from https://premm.dfci.harvard.edu

GBD 2019 Cancer Risk Factors Collaborators. (2022). The global burden of cancer attributable to risk factors, 2010-19: A systematic analysis for the global burden of disease study 2019. Lancet, 400, 563-591. https://doi.org/10.1016/S0140-6736(22)01438-6

Gruber, P., & Zito, P. M. (2022). Skin cancer. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK441949

Jang, M. K., Hershberger, P. E., Kim, S., Collins, E. G., Quinn, L. T., Park, C. G., & Ferrans, C. E. (2019). Factors influencing surveillance mammography adherence among breast cancer survivors. Oncology Nursing Forum, 46(6), 701-714. https://doi.org/10.1188/19.ONF.701-714

Johns Hopkins Medicine. (n.d.). Prostate cancer risk assessment tools. Retrieved October 28, 2022, from https://www.hopkinsmedicine.org/brady-urology-institute/conditions_and_treatments/prostate_cancer/risk_assessment_tools/smith

Kappen, S., Jurgens, V., Freitag, M. H., & Winter, A. (2019). Early detection of prostate cancer using prostate-specific antigen testing: An empirical evaluation among general practitioners and urologists. Cancer Management and Research, 11, 3079-3097. https://doi.org/10.2147/CMAR.S193325

Kitson, S. J., & Crosbie, E. J. (2019). Endometrial cancer and obesity. The Obstetrician & Gynaecologist, 21(4), 237-245. https://doi.org/10.1111/tog.12601

Loomans-Kropp, H. A., & Umar, A. (2019). Cancer prevention and screening: The next step in the era of precision medicine. npj Precision Oncology, 3(3), 1-8. https://doi.org/10.1038/s41698-018-0075-9

Lubejko, B., & Wilson, B. (2019). Oncology nursing scope & standards of practice (1st ed.). Oncology Nursing Society.

Melanoma Research Alliance. (n.d.). Melanoma staging. Retrieved October 30, 2022, from https://www.curemelanoma.org/about-melanoma/melanoma-staging

National Cancer Institute. (2017). Harms of cigarette smoking and health benefits of quitting. https://www.cancer.gov/about-cancer/causes-prevention/risk/tobacco/cessation-fact-sheet#what-are-the-immediate-health-benefits-of-quitting-smoking

National Cancer Institute. (n.d.-a). The breast cancer risk assessment tool. Retrieved October 28, 2022, from https://bcrisktool.cancer.gov/index.html

National Cancer Institute. (n.d.-b). The colorectal cancer risk assessment tool. Retrieved October 28, 2022, from https://ccrisktool.cancer.gov

National Cancer Institute. (2019). Symptoms of cancer. https://www.cancer.gov/about-cancer/diagnosis-staging/symptoms

National Cancer Institute. (2021). What is cancer? https://www.cancer.gov/about-cancer/understanding/what-is-cancer

National Cancer Institute. (2022a). Cancer genetics risk assessment and counseling (PDQ®)- Health professional version. https://www.cancer.gov/about-cancer/causes-prevention/genetics/risk-assessment-pdq

National Cancer Institute. (2022b). Screening tests. https://www.cancer.gov/about-cancer/screening/screening-tests

National Cancer Institute Division of Epidemiology and Genetics. (n.d.). Tools & resources. Retrieved October 28, 2022, from https://dceg.cancer.gov/about/organization/tdrp/bb/resources

National Cancer Institute Office of Cancer Survivorship. (2022). Statistics and graphs. https://cancercontrol.cancer.gov/ocs/statistics

Nettina, S. M. (2019). Lippincott manual of nursing practice (11th ed.). Wolters Kluwer

Penn Medicine. (2021). Health risk assessment tools. https://www.pennmedicine.org/updates/health-risk-assessment-tools

Rahib, L., Wehner, M. R., Matrisian, L. M., & Nead, K. T. (2021). Estimated projection of US cancer incidence and death to 2040. JAMA Network Open, 4(4), e214708. https://doi.org/10.1001/jamanetworkopen.2021.4708

Saric-Bosanac, S. S., Clark, A. K., Nguyen, V., Pan, A., Chang, F., Li, C., & Sivamani, R. K. (2019). Quantification of ultraviolet (UV) radiation in the shade and in direct sunlight. Dermatology Online Journal, 25(7), 1-6. https://doi.org/10.5070/D3257044801

Shulpekova, Y., Nechaev, V., Kardasheva, S., Sedova, A., Kurbatova, A., Bueverova, E., Kopylov, A., Malsagova, K., Dlamini, J. C., & Ivashkin, V. (2021). The concept of folic acid in health and disease. Molecules, 26(12), 3731. https://doi.org/10.3390/molecules26123731

Siegel, R. L., Miller, K. D., Fuchs, H. E., & Jemal, A. (2022). Cancer statistics, 2022. CA: A Cancer Journal for Clinicians, 72(1), 7-33. https://doi.org/10.3322/caac.21708

Smith, R. A., Andrews, K. S., Brooks, D., Fedewa, S. A., Manassaram-Baptiste, D., Saslow, D., & Wender, R. C. (2019). Cancer screening in the United States, 2019: A review of current American Cancer Society guidelines and current issues in cancer screening. CA: A Cancer Journal for Clinicians, 69(3), 184-210. https://doi.org/10.3322/caac.21557

US Preventive Services Task Force, Grossman, D. C., Curry, S. J., Owens, D. K., Barry, M. J., Caughey, A. B., Davidson, K. W., Doubeni, C. A., Epling, J. W. Jr., Kemper, A. R., Krist, A. H., Kubik, M., Landefeld, S., Mangione, C. M., Silverstein, M., Simon, M. A., & Tseng, C. (2018). Behavioral counseling to prevent skin cancer: US Preventative Services Task Force recommendation statement. JAMA, 319(11), 1134-1142. https://doi.org/10.1001/jama.2018.1623

US Preventive Services Task Force. (2021). Final recommendation statement: Lung cancer: Screening. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/lung-cancer-screening

Wolf, A., Fontham, E., Church, T., Flowers, C., Guerra, C., LaMonte, S., Etzioni, R., McKenna, M. T., Oeffinger, K. C., Shih, Y. T., Walter, L. C., Andrews, K. S., Brawley, O. W., Brooks, D., Fedewa, S. A., Manassaram-Baptiste, D., Siegel, R. L., Wender, R. C., & Smith, R. (2018). Colorectal cancer screening for average-risk adults: 2018 guideline update from the American Cancer Society. CA: A Cancer Journal for Clinicians, 68(4), 250-281. https://doi.org/10.3322/caac.21457

World Health Organization. (2022a). Cancer. https://www.who.int/news-room/facts-in-pictures/detail/cancer

World Health Organization. (2022b). Preventing cancer. https://www.who.int/activities/preventing-cancer

 Yarbro, C. H., Wujcik, D., & Gobel, B. H. (2018). Cancer nursing: Principles and practice (8th ed.). Jones & Bartlett Learning.