Colon Cancer Screening Test

>> at this time all [inaudible] on the own mode. during the question and answer session please press star one on your touch tone phone. this conference is being recorded. if anyone has any objections,

you may disconnect at this time. now i have to go ahead and turn the call over to candice manor, ma'am you may began. >> candice manor: great! thank you julie. welcome and thank you for joining us

as the kick off our fourth session pilot of education seminars designed to provide the content, tools, and resources necessary for public health professionals to adjudge cancer as a public health problem. my name is candice manor and i'm

with the national cancer institute, office of communications and education. today's seminar understanding cancer, will include overview of cancer diagnosis and staging information. at the conclusion of our session today,

you will be able to demonstrate a basic understanding of cancer etiology, prevention, detection, and diagnosis. it is a pleasure to introduce our presenter for today, ms. linda perico. linda perico is a public health

advisor in the national cancer institute, office of communication and education. ms. perico is a registered nurse by training and her background includes the unique opportunity to experience oncology practice from the community, academic

and government settings. in 1983, with the nci's creation of the community clinical oncology program, she was hired by the wichita [inaudible] as their first oncology research nurse. in 1992, ms. perico moved to washington d.c. to work

at the lombardi cancer center at georgetown university in their newly created oncology nurse case management program. she managed the multidisciplinary clinic for early stage breast cancer patients and coordinated care for a caseload

of breast cancer patient. during that time, she completed a graduate degree in oncology nursing at georgetown university. ms. perico in her government service in 1999 with nci's division of cancer prevention,

where she was the head of the protocol information office for five years. ms. perico moved to nci's office of communications and education in 2004 and spent several years working with the nci's cancer information service to educate and support the information

specialist capacity to effectively teach the public about clinical trial. now in oce's office of partnership and dissemination initiative, she leads the programmatic effort to implement and evaluate nci's accrual net.

ms. perico is the member of the oncology nursing society, the american society of clinical oncology, and the society of clinical research associate. i have just a few quick housekeeping items before i turns things

over to our presenter. the archive for today's session will be posted to the education and training case, located on cancer.gov approximately one week from today's session. we invite your questions

throughout today's presentations. you can post questions live through the operator by pressing star one on your phone. you will then be placed in the queue for the live q&a session

at the end of today's call. you can also send a question via the q&a tab at the top left of your screen. we will get to as many calls and questions as we can in our time today and we'll alternate between online

and live operator calls as necessary. and without further ado, today's presenter ms. linda perico. >> linda perico: thanks very much candice. good afternoon everybody and thank you

for joining our webinar this afternoon. i'm joined here in this conference room with candice and with my colleague annette galosy, and annette will be helping to facilitate our question and answer time

at the end and if i stumble on the basic science questions and annette's going to be here as my backup because it's so not my forte. but we're delighted that so many people registered for this webinar and we know that people will, will continue

to join as we get started and i just want to let you know in the audience know that you're joined by a wide variety of health professionals, cancer control specialists, public health specialists, educators, trainers,

there's a number of clinical people joining us on the call today including clinical research nurses and we know with this broad spectrum of people, we probably have a broad spectrum of experience, joining on the phone,

everybody from novices to experts and that's fabulous and our goal for today is that everybody walks away with either a refreshed understanding of information that they haven't focused on for a while or for those of you that are new to the area

of cancer, starting to walk away with some foundational concepts and some foundational knowledge and certainly for all of you to walk away knowing about really valuable resources that are available to continue your learning, resources that are available

through the national cancer institute. so, we will get started. as soon as i, oh hi, that's me. hello everybody. moving on, so our objectives for today are we're going to start, in the beginning we're going to talk a little bit

about how cancer develops, we'll discuss the purpose of screening and early detection, we'll talk about a number of barriers with screening why people don't participate in scheduled screening

and we'll spend some time talking about how cancer's diagnosed in state and then as candice said at the end, we will have time for, for questions and answers. so what is cancer? starting at the beginning, what is cancer?

the word cancer just remember it's a term for disease is that which abnormal cells divide without control and invade nearby tissues and can also invade tissues distant from the origins with location at origin. so we start in the beginning,

looking at normal cells and how normal cells grow. so this may be basic and familiar to most of you and new to some of you, but my explanation is going to be pretty simplistic, so no one will get lost. the body is able to as you know,

the body's composed of many different kinds of cells, many types of cells and in normal tissues the rate of new cell growth and old cell death remain a constant and it's a homeostatic mechanism whereby the number of new cells is the right amount

when cells finish their usable function and when they're ready to die, they go through a natural process of self suicide, also known as apoptosis and we're able through this very structured, very organized

and amazing process to always have the right number of cells that we need and the right places for our body to do its work. so you know you've always got just enough skin cells, you've always got just the right number of skin cells.

you got just enough hair cells or may be not, or in my case just too many fat, no we won't go there. but so just to know that there's a normal process that's very regulated that allows the body to maintain a

homeostatic pattern. what happens in cancer is the bottom half of the slide, we see the process of carcinogenesis and we see the best cell because changes to the dna will cause mutations that each time the cell divides,

this mutations continue and eventually through this process with the intervening genetic changes and mutations continuing, the normal mechanisms that control growth are overcome does allowing for overpopulation

and uncontrolled growth of cells and so that ends up with what you see on the right hand side of slide which is a tumor growth also known as the neoplasm and so in this slide we see how that loss of growth controls, arouse the cells

to continue dividing in a way that wouldn't be normal in a way that doesn't support the structure and the function of that particular tissue and as we move beyond through this slide, you can see on the bottom, the, one of the first hallmarks

of a neoplasm which is you see those cells invading through the, the basement membrane of a cell and moving into underlying tissue. so this demonstrates the ability of cancer to invade locally within the areas that in

which it started and moving into this next slide, this highlights a couple of things for us. the first is, the difference between a benign tumor and a malignant tumor. so benign tumor like a benign fibroid tumor

for example will grow locally, but they tend to be enclosed in a fibrous sheath and they're stopped from having that uncontrolled growth and for the hallmarks, the difference between a benign tumor is while it may grow locally,

it doesn't have that characteristic and doesn't have the ability to invade locally or to metastasize widely. so a benign tumor can generally be removed, once removed it's not going to come back.

on the right hand side of the slide, we see that continued progression over time, continuing genetic changes and mutations that allow for that uncontrolled growth which sees an enlarging tumor mass and we see

on the far right hand side of this slide, this hallmark of cancer that makes it really a dangerous disease and that's the ability of the cancer cells to move into the blood system, into the lymphatic system and thereby traveling

to distant parts of the body. so you're probably familiar with the term metastasis which refers to this very process. and so you see at the bottom the occurrence of time, so this process happens over a long period

of time depending upon the cell of origin, the nature of the changes going on that, that wrap, that division of cells and the growth of the tumor mass may occur more rapidly or less rapidly in some cases. but in all cases,

it's over a period of time and usual, in many cases a period of many, many years worth of time and that fact is important to remember because that creates the opportunity for prevention and for early detection of the screening

that we'll be talking about. okay, so moving on to genes and cancers. so this goes back to very basic biology and what we said with the cancer results in a loss of normal growth control.

so here's a really quick and simple look at how that happens. so we see on the right in the nucleus of the cell, the packets of dna molecules called chromosomes and inside the chromosomes

are genes. genes are inherited instructions and these genes instruct a cell on how to build a specific product and in most cases that product is a, a particular kind of approaching. so we said that changes occur

in the genes that contribute to cancer. so what kinds of things is it that might change or mutate these genes. so on the left we see a variety of scenarios. the first is chemical may cause genetic changes.

so chemical we can easily think of numerous carcinogens, the one that comes you know first to the top of mind is cigarette smoke. secondly, viruses may play a role in genetic changes, viruses injecting their genetic material into that of a cell

and when we think of viruses, we think about the human papilloma virus, the hpv virus and finally radiation may cause mutations through damaging of, damaging of genes and heredity plays a role because people may pass on alterations in their genes

that makes their offspring more susceptible to a particular type of cancer. so this has been like just a really, really superficial look at some of those basic things that contribute to the development of cancer

and helping you to understand the difference between benign and malignant stage and a little bit of that process, but here's a couple of resources on nci's website cancer.gov that i would really encourage

you to take a look at whether you fall into the novice range or into the expert range, both of these i think will appeal to both groups of learners. the first is a series on cancer.gov called the

understanding cancer series and there's a series of powerpoint slides with notes attached to them and in the understanding cancer series, there's about 20 different topics ranging from the basics of cancer all the way

to genomics and proteomics and angiogenesis and personalized medicine, so it's an incredibly wonderful resource, i would encourage you to take a look at that and the second is the nci cancer bulletin and if you are not already a regular reader

of the bulletin, i would really encourage you to sign up for it, allow it to be deliberate into your email inbox and to take a look at the research highlight because the bulletin does i think one of the best jobs of,

of any resource that i've seen and taking the latest scientific and technical advances and really being able to translate it into understandable language that allows you to take that information and put it into context and really start

to develop some understanding of it. in the latest cancer bulletin was a great article, i just read it this morning, but i probably can't repeat it to you, but it was about new genes that were discovered in melanoma

and it's some really serious important new findings. so anyway, please take a look at those resources. moving on, so when we think about cancer, where does cancer develop, it can develop basically any place in the body.

but there's essentially four different types of cancer, different large classification categories. the first being carcinoma, carcinomas are the most common type of cancers and they arrive from cells to cover either external or internal body

surface is the lining of organ. so lung, breast and colon you see here and you know that these are the most frequently diagnosed cancers in the united states. carcinomas also occur in the bladder as well

as in the prostate. we look over on the other side, we see the leukemia which you know are cancers of immature blood cells that grow in the bone marrow and then spill over and accumulate in large numbers in the peripheral blood stream

and block out the other normal constituents of the blood. lymphomas are cancers or i'm sorry, arise in a lymph nodes and other organs of the lymphatic systems and sarcomas as we see at the bottom are cancers

that arise from cells that are found in supporting tissues of the body such as bone, cartilage, fat and muscle. another category that's not reflected up here but you might be familiar with is the cancer called

myeloma sometimes refer to as multiple myeloma and myeloma is the cancer that spreads from plasma cells in the bone marrow. so when we talk about for those of you that are new to the field of cancer when we talk about names of cancers

and cancer diagnoses, we usually combine these latin prefixes that refer to a part of the body along with that larger categorical naming that we just looked at. so for example in this picture, adeno means gland, so cancer of a gland

or gland cells are called adenocarcinoma for example a breast adenocarcinoma, a colon adenocarcinoma. likewise, as we see at the bottom osteo refers the bone so an osteosarcoma would be a cancer of the bone.

just to help you not in the medical field decide for some of that medical language that you run into. okay, move on to the next section of this presentation which is looking at cancer screening and early detection.

some types of cancer can be found before they start to cause symptoms. so as we look at that timeline, we said that sometimes years can lapse, elapse before cancer is detectable, before it's large enough to cause the symptom,

create a problem, draw somebody's attention to it, take it to the doctor and so that long lead time provides us with a great opportunity to be able to find cancer as it's developing and as it's dividing, so it's detectable

but it hasn't demonstrated itself in terms of symptoms that would call your attention to them. so and the reason that we want to find it early is because the smaller cancer is the earlier it's found, the more treatable it is

and the greater is the likelihood of the person being able to like survive the cancer diagnosis. [ pause ] >> linda perico: so when we talk about cancer screening, screening is checking for cancer in a person

that doesn't have any symptoms of disease like we said. so keep in mind the people that we're looking at here are an asymptomatic population of healthy individuals and the goal of screening as we said is to detect cancer before it grows

and spread or metastasizes. so screening tests are not in and of themselves meant to diagnose cancer, they're meant to be able to demonstrate if there's an abnormality or not and if there is an abnormality, further testing would be

required and those would be referred to as diagnostic test, so the purpose of those tests would be to say, is this an abnormality cancer or is it not cancer. so people that have certain higher risk diseases, for example people

that have a familiar heredity, hereditary genetic change that would predispose them to developing colon cancer at a very early age for example that population of people would be recommended to start colon cancer screening at a much earlier age.

likewise, women with a very strong family history of breast cancer would potentially start screening studies earlier than what a general risk population would. so if we look at the types of screening test,

we know that essentially there're several diseases that are amenable to screening and the purpose of the screening as we said is to decrease the mortality and the number of deaths related to cancer. so we know that the use

of screening mammograms is effective in reducing death due to breast cancer. as well we have known for a number of years that pap test can reduce the death due to cervical cancer and certainly colon cancer by using a variety

of different tests can reduce death related to colon cancer. prostate cancer in psa we've got question marks because as you know that with standard practice for quite a long time and know you've seen more information in the news recently

like questioning the utility of that. so there's a lot of issues that if you follow the news either the scientific literature or the lay literature as well, you see a lot of issues related to cancer screening and so as the bottom line

with cancer screening is the test needs to decrease the chance of dying from cancers. so that's asking a different thing than can it detect more cancers, so purpose is decrease the number of death. it's important to think about a particular risk

that can be associated with the screening. for example with the colonoscopy there's always a risk of perforation, although it doesn't, it doesn't happen frequently. you may have heard the term false positive

and false negative in conversations or in, in your reading about cancer screening. a false positive reading on a screening test means that your mammogram detected something that it called positive when indeed it,

it wasn't cancer and so immediately what comes to mind are the impacts of, of false positive results knowing that additional tests will be required, there's the cost of additional tests, there's potential complications

with additional tests, to say nothing about the anxieties that potentially have any cancer diagnosis evokes in anyone. a false negative result on the other hand is also not good, but a false negative refers to the test reads

negative when indeed a cancer was present so just as devastating on that end of the coin. so the science around cancer screening continues to change and the important thing in cancer screening is

that we continue to do clinical trials that test new screening modalities, we continue to look at the evidence, we continue to look at the science, we continue to have scientific debate

and we continue to incorporate strong evidence based practices into, into our recommendations and into practice. and we all know that communicating changes around screening to the public is challenging.

so we can, we watch as that you know unfolds in the lay literature very frequently. okay, so let's talk for a moment about barriers of screening. so there's a whole host of them and commonly we, we know that people may be

scareful of screening for variety of reasons, one being not wanting to have that colonoscopy because god forbid may be there's something there that would be my husband. lack of knowledge may be a reason, finances for lack

of access to screening may be a reason as well as communication or beliefs about illnesses and other cultural things. and even like for those of you that are of the age when you need to be you know participating in screening practices,

we all know that it's difficult to get that mammogram scheduled for example because you know something else just got in the way. so it's something where we all need to be knowledgeable about the screening guidelines

and we all need to be personally responsible and accountable for our own screening practices as well as helping to educate those around us about appropriate screening practices and enabling people to do that.

so cancer detection, so changes may arise in the body that give us a sign that that cancer may be prevalent, so let's talk a little bit about what those kinds of things are. so symptom is a sign to you that something's not quite

right, there's a change and the thing to remember is that most symptoms that are that people experience in their bodies are not due to cancer and to remember that early cancer usually doesn't cause pain. so let's look at some

of the possible symptoms of cancer. this list might be familiar to many of you, but it's, it's always worth repeating one more time. a thickening or a lump that wasn't there before, a new mole or a change

in the existing more, a sore that doesn't heal, hoarseness or cough that persist over time and new change in the bowel or bladder habit, having discomfort after eating, having difficulty swallowing, unexplained weight change, unusual bleeding or discharge,

feeling very weak or very tired. as well you should pay attention to your body if you, you know for any sort of unexplained symptoms commonly such as a progressive weight loss over time that you can't explain, fever or persistent fatigue, so,

oh and pain. so all of these are things that you know people need to take personal responsibility, be vigilant about knowing your body and understanding and recognizing changes when they occur

and seeking appropriate medical advice and intervention as needed. okay, so let's move on now to cancer diagnosis and staging. diagnosis of cancer, so let's say you either been through a screening test and there's an abnormal finding

or may be this scenario is you found a change on physical exam and there's a concern that it might be a sign of cancer so may be some studies have been done, but this isn't just you know accumulating, it's beginning to gather diagnostic information

if not definitive of biopsy or the surgical removal of the small piece of tissue for examination is the definitive diagnostic tool for establishing a diagnosis so let's talk a little bit about that biopsy. so there's a number of ways

that we can obtain the tissue and one of the ways that we can get tissue is through a procedure called an endoscopy and certainly for those of you in clinical practices is very familiar information but may be newer

to others of you. so an endoscope is basically a long hollow tube that usually has a light on the, not usually it has a light on the end of it and it has little pinchers and that long hollow tube can be inserted into any number

of openings to take a look. so when the tube is inserted into the colon, obviously that's a colonoscopy or you can insert the tube down into the lung that's a bronchoscopy. you can even use that tube to make a small incision on

and insert a tube into a closed cavity such as the abdomen thereby performing what's known as the laparoscopy. you can insert it into the chest doing a thoracoscopy or a mediastinoscopy and so all

of these users, these are different examples of ways that an endoscopic procedure can be used to follow up an abnormal finding for the purpose of taking a piece of tissue in an effort to establish a

definitive diagnosis. okay, another method that's commonly used is what's called the needle biopsy. there's two different kinds of needle biopsies, the first thing fine needle aspirate commonly referred to as an fna as well

as a core biopsy. so a needle biopsy can be used if a mass is discrete, you can sort of get it between your fingers, you can feel it underneath the skin. a common example of this and when fna is commonly used is

to evaluate a breast mass and so if you feel a breast mass, you can put a long thin needle into it, you can withdraw cells, you can use that to figure out if that might be a cyst which is just a benign fluid filled stack or if it's solid, and when those cells are

withdrawn those cells are looked at under a microscope and that's referred to it as cytology and so looking at those cells for cancer. so one of the benefits of doing a fine needle aspirate procedure is it's easy to do, it can be done in the office,

one of the drawback is that you might not be able to get enough cells to definitively make a diagnosis. but fna is, it's used frequently. another type of needle biopsy that could be done is referred

to as a core biopsy and as you might have guessed, the core biopsy used as a, used is a larger bore needle and it's able to draw out a larger piece of tissue for a microscopic examination. core biopsy might be done either freehand if you can like feel

that lesion you know well enough and get a hold of that well enough to get the core needle into it or in some cases the placement of the needle may be guided by a radiology, radiology technique for example using ultrasound

or using some sort of a 3d imaging and the core needle has a special cutting edge on it and like i said, it can take a larger sample of tissue and both of these procedures are done with just a little bit

of local anesthesia. and then finally are, are surgical biopsies, the larger procedure done with anesthesia in an operating room may be incisional or may excisional and the purpose of an excisional biopsy would be

to go in and remove the entire tumors, so using breast again as an example and excisional biopsy of a, of a palpable mass or nonpalpable mass to remove the entire tumor or the, the entire mass trying to take a realm

of normal tissue along with it. also using the breast again as an example, an example of an incisional biopsy would be in the case of a locally advanced breast cancer where sometimes the entire breast or much of the breast as in case

in tumor and in that situation it's not an operable situation, but you can go in, do an incisional biopsy and be able to take tissue of making a diagnosis. okay, so the next concept that we're going to talk

about is what's called, refer to is grading and grading is a microscopic examination of the tissue that helps determine the aggressiveness of the behavior of the cancer. so grading is done looking at tissue under the microscope

and it's characterizing looking at individual cells and so the tumor may be defined as well differentiated or poorly differentiated and a well differentiated and a well differentiated tumor, the cells under the microscope will, can function more

like the cells of the originating tissue. so using breast cancer again the cancer cells look still somewhat like a breast cell and so the grading scale ranges from grade 1 to grade 4 and so a well differentiated tumor may be graded a 1

or a grade 2 and it moves down the continuum to a poorly differentiated tumor and at that end of the spectrum the individual cells have a bizarre and a highly abnormal appearance. there's very little structure

or character of those cells that would remind you of the cell of origin and that's a type out there should be grade 3 to 4 for poorly differentiated and so what you would expect this piece of information gives you another tid-bit

as you're planning for treatment as thinking about prognosis because of well differentiated tumor by natural history it's going to would tend to behave not as aggressively as a poorly differentiated tumor. so we'll talk now

about staging in cancer. staging, so grading was looking at individual cell. now we can think about staging as being about the whole body. the staging is the process that tells the clinician how far the cancer has spread throughout the body and if we look at this

as an example, so with staging, the earlier something is caught has we've already said before a couple of times, the better the prognosis. if it's small and can be removed, your chance of survival is much better

than if it spread either regionally or distantly in the body. so this gives you a pretty graphic demonstration of the role that stage plays in overall survival. this particular slide is showing, is using melanoma

and it shows that the five year survival rate for patients of melanoma by stage. so you can see on the left hand side, stage 1 and that 1 is a little difficult to read there. the people diagnosed

with stage 1 melanomas, early stage and what that tells us is that the melanoma was not big, it was not spread, it was very localized and very thin and you can see here very treatable because indeed nearly

close to 100% somewhere over 90% of patients are alive at five years after a diagnosis of stage 1 melanoma. but stage 2, meaning that that tumor was either in the case of melanoma was either thicker, more abnormal,

a little more spread locally that stage 2 person has about a 30% less, has about a 30% lower survival at five years than if it were detected earlier and obviously wit stage 3, meaning that the disease has spread probably

in the melanoma staging system, it's spread to a, a near body lymph node, these people have a, a much worse prognosis. so this is a pretty dramatic demonstration of why detecting and finding cancer earlier leads to better outcome.

okay, so staging is important because as we said it helps to determine the extensive disease, it, it's critical to planning treatment. treatment is the determined by stage and it influences the person's prognosis and so when we look at staging,

staging is focused on the most common site for metastasis, so what does that actually mean. so when we look at any type of cancer, we know through looking at cancer over time that there's a natural progression

for each different type so we know for example that er, estrogen receptor positive breast cancer is certain type of breast cancer has a propensity when it metastasizes to move first to the bone. we also know that estrogen receptor negative

breast cancer may move to other places, for example the lungs and the brain and the liver. so with each disease we basically know where we can expect cancer to spread, use that information to define what the staging

workup for somebody diagnosed with a new cancer would be and so the kinds of things that are included in a staging evaluation would include a physical exam, we'd be looking at laboratory test and the types of lab tests

that would be considered would be a complete blood cell count, doing a regular chemistry panel. there are a number of disease specific tumor markers and some are listed here that help us to, that helps to provide prognostic information about that disease

and some of these tumors markers are really helpful tools in following response to treatment or potentially recurrence of disease into the future. but so for particular types of cancer, a disease specific tumor marker may be evaluated.

staging workups usually include a variety of radiologic studies and these again are going to be dictated by where that particular type of cancers prone to spread and so any one of these, any combinations of these might be appropriately

used for particular there's four common stages the first being in situ disease, this is early cancer that do not spread to neighboring, neighboring tissues. example of this you may be familiar with this,

with the term dcis, which stands for ductal carcinoma in situ. the next would be local disease which means the cancer is only found in the organ and which has started to grow, so if you will it's localized to right in the area of origin. regional disease means

that cancer cell has spread cyst surrounding tissues or to lymph nodes. so you recall in the earlier diagram where the cells are being shed and to the blood stream, so we see the results of that with cancer being involved

in the lymph node. and then distant spread means the cancer obviously has spread to other organs or other systems of the body. so if we look at staging, of classification systems that are used and the typical classification

system that's used for solid tumors is what, is referred to as the tnm system and it stands for tumor size lymph node status and distant metastasis. so when this staging criteria is applied, there is a little subscript numbers

that are associated with it, so for example in a breast tumor if the tumor is between say 1 and 2 cm that would be denoted as a t1 tumor size. a slightly larger tumor might be denoted as a t2 tumor size. the same applies with lymph node status.

if there is no lymph nodes involved then it would be denoted as n0, if there are positive lymph nodes then it would be denoted as an n1 and the same for metastatic disease, no distant disease would be an m0 and the presence

of metastatic disease would be an m1 and so whom we'd look at individual cancer diagnoses, it's very common you'll commonly see this tnm staging written down and it, you might be a t, t1n1m0 type of thing. hematologic malignancies on the other hand have their

specialized staging systems, these are applied to leukemias, lymphomas and myeloma. and staging, it's important to know that staging that lots of evidence is collected looking at if disease over time of these staging systems are to be able to provide prognostic

information and integrate that with informing decisions about treatment. so, to summarize we're really at the end of our content and so let's just take a quick look back at what we've talked about today and review with some take on that.

so basically number one cancer results when genetic changes or mutations overcome the normal control mechanisms, cancer is characterized by its ability to invade locally and metastasize widely, prevention is key. screening asymptomatic

population can decrease deaths from colon cancer, breast cancer and cervical cancer and we use biopsies to obtain tissue. tissue provides the we talked about grade, we're referring to the appearance

of individual cancer cells, we talked about stage, we're talking about the whole body and the extent of cancer across the body and to know that resources are available and thinking of resources but just referring you again

batch of the cancer.gov website and here you're going to find information that's relative to both health professionals and patients, patients and lay audiences and you'll find a wealth of information online and it's divided up according

to disease as well as according to various cancer topics, you'll find information in each of the cancer diagnoses the detail is for health professionals as well as for lay audiences. the other thing that if you're not already aware

of the national cancer institute's cancer information service, so 1800 for-cancer all number as it's been, been known for over 30 years of service now. so the cis is manned with or persons with information specialists who are very,

very well trained and use ncis cancer information resources to answer questions and to be able to discuss cancer topics with some, with public audiences and so for those of you in the health professions that work with patients,

i think that the cancer information service can really be seen as an adjunct to the teaching that you do with patients because you've got a lot of information to people particularly around a new diagnosis

and i think i would encourage you to meet patients with the 1800 for-cancer phone number and they can use the information specialists to help them continue that discussion to be able to answer questions and to really empower the

patient with resources that are available. so we come to the end of my content and i hope you all found this helpful and now we'll turn it over for questions and answers. >> candice manor: great. thank you linda

for laying the foundation for our understanding of cancer with your presentation today. the second half of this call will be devoted to your questions and we encourage all of you to be active participants. in addition

to having linda available to answering questions you might have, we also have with us today ms. annette galassi with nci's office of communications and education. annette is a registered nurse with over 25 years of experience in oncology.

annette will be moderating the q&a session and answering any questions that you might have today. as a reminder please press star one to be placed in the queue to ask your question. or if you would refer you can also submit your questions using

the q&a feature at the top of the screen. >> annette: okay, candice and we do have one question and is if the slide will be available to the attendees after today's presentation and so we can make arrangements for the posting

of the slides along with the posting of the audio files on the education and training page of the cancer.gov website. >> okay. operator do we have any questions on the line yet? >> i, i do have one

question here. one moment. karen gregory your line is open. >> karen gregory: yes, my question was your answer about the slides being placed online. i was unable for some reason the link would

not open, i tried various ways to have that open, but i was able to listen to the entire call, so thank you very much. >> sure, we're sorry that, that happened to you today, but we'll be posting those slides.

>> karen gregory: thank you. >> right now i show no further questions. as a reminder if you like to ask a question over the phone, please press star one, please send me your phone and record your name.

one moment to see if we have any other questions over this phone. >>annette: okay. we do have one question that's come in online and that is in reference to recommended ages for various types of screening and how often one should

get screened. so let's take those sort of one at a time. the first perhaps being what has become the most controversial and that is screening for breast cancer. and you will may have been privy to the [inaudible] if you will

that was in the media about a year or so ago when the u.s. preventive services task force came out and changed their recommendations for screening mammogram somewhat. rule of thumb is

to dark screening mammography at the age of 50 that consideration should be given to one's family history and personal history and also this should be done in the context of a discussion with one's healthcare provider so that patients can really be

making an informed decision about what the risks and the benefits are of screening mammography and that in fact really goes not only for screening mammography but for other diseases as well. okay, let's next take cervical cancer that's the other cancer

that we screen for and cervical cancer screening is done with pap testing and that usually begins at the age at which a young woman becomes sexually active and that is of course going to vary from woman to woman and again that's discussion

that is held with the woman and her healthcare provider as to when exactly to begin those, to those screenings. the, i guess next group of disease is or the next disease that we screen

for is the colon cancer and let me just remind you all that there are really several modalities that can be used for colon cancer screening. we have fecal occult blood testing, we have immunohistochemical testing, we have flexible sigmoidoscopy,

double contrast barium enema and screening of colon, colonoscopy. those really are the range of screening studies that can be done for colon cancer. screening should begin at the age of 50 again unless

there is some sort of a family history that necessitates screening to begin earlier. if there is a family history of early onset, colon cancer and the rule of thumb for that tends to be five years sooner

than the youngest person that was diagnosed. so if there's a strong family history of colon cancer and the first or, or the youngest person to get colon cancer in that family was 45 years old then the recommendation would be

first degree relatives begin screening at 40, so those are just some general rules of thumb for breast, cervical and colon cancer screening and as linda pointed out earlier these are the diseases for which we know screening does make a difference

in terms of mortality. okay, we have another question. the question is around psa and oh well i think we, we covered this. it was around psa, mammography and pap testing. i guess the only thing that we really looking cover is,

is psa and i know linda alluded to the controversies surrounding psa screening and i think that the, the controversy of that really is related to the fact that you know do we know that screening with psa saves lives.

and in order to answer that question nci has undertaken the plco trial for prostate, lung, ovarian and colon cancer screening trial. very large screening trial that involves i want to say off the top of my head

over 10,000 participants linda might know a little bit better than me what that number was and we are awaiting that data to find out what affects screening with psa for prostate cancer will have. so you know right now the for prostate cancer screening do

tend to be variable, you have organizations like professional societies of urologists that do tend to recommend, psa screening, but according to the u.s. preventive services test for us recommendations which is what guides our

practice here it is unclear what the dataset of screening with psa is. alright. >> i do have a question over the phone. would you like to take that? >> sure. >> okay. atul sarani your line

is open. >> atul sarani: hi! my question is advances in personalized medicine for cancer impact screening and early detection given that doctors can now weigh in one's genetic background and medical history.

>> annette: i think that that's a fabulous question atul, and it's nice to hear your voice by the way. i think that as we learn more and more about the biology of cancer, we'll have a better understanding of people's risk for cancer.

i don't think we're there quite yet, we are using tumor profiling in some diseases to make treatment decisions. for example, the [inaudible] of adjuvant therapy for breast cancer is being dictated by something that we know about, excuse me,

people tumors like their her-2 neu status. i don't think that we're quite there yet when it comes to screening. there are genetic alterations that we know exist in certain families that increase their risk

for the development of cancer and factors that in we're making screening and in some cases for prophylactic surgery to people with genetic ulcerations, but although we're, we're finding various ulcerations

as we study tumors we're not necessarily at the point where we know what to do with that information. linda i don't know if there's anything you want to add to that. i would just add you might have read or others

who might have read about the need to establish validate biomarkers, so biomarkers being an indicator may be of susceptibility, may be of risks, but being able to impart additional and important information sort

of in that early, in that early phase so we can like identify people using a blood test about who's at high risk and so to characterize people's risk categories and work towards prevention and one of the difficulties

in that area is that when you establish a test you've got to get to the point where that test is standardized that every that doe the test if using the same technology and the technology is yielding a consistent and standardized result and so there's a lot

of effort underway now to validate biomarkers because a lot of biomarkers have surfaced as you know effective biomarkers of predictability or susceptibility but there needs to be a process of standardization

where when one lab does it equivalent and consistent results are, are received across the board. so i think that's another area to keep an eye on, there's an area that holds a lot of promise. thanks for the question though

that was great. >> and right now i see no further questions like to ask a question please press star one. please send me your phone one moment let me see operator while we are waiting, we do have question

about where one can find cancer education information for non-english speaking populations with high levels of illiteracy. so this looks like a good opportunity to make a, a plug for cancer.gov espanol.

we do have a dedicated website for spanish speaking individuals and, and health professionals as well. we also have a lot of our materials that are available in spanish and with a focus on plain language

so that they are more approachable if you will for people with low literacy level. finally we have very few materials available in some vietnamese i believe it is dialogs, not dialogs, dialects but those are primarily

for cervical cancer screening, that there is any information there for breast cancer screening and i don't think we have any treatment related information. we do have a web, a webpage on our website. you can find a link to it

if you go to the cancer.gov website on the left hand bar you'll see a link to our publications bordering service and if you click on that link you can search more publications by language, by literacy, by cancer topics. so i would encourage you

to go there and take a look at, at what we have available. >> i do have another question >> annette: sure. >> aubrey your line is open. >> aubrey: hi! yes, i want to follow up on that question populations and those

with low literacy. what materials are you aware of that have been designed for children whether it's either pediatric cancer patient or children of like that have relative who are going to cancer or just a general population starting

to educate kids about what cancer is and how to prevent it for healthy lifestyle choices? are you aware of any documentation on this for children? >> annette: great question. we do, let, let me start

with the easier piece of that and that is to mention that we do have a page on cancer.gov that is directed specifically towards adolescence and young adults with cancer and i believe you can, the easiest way to find it is

by going to the search box in the upper right hand corner and just typing in young adults and cancer, so we have something for that population. we also have materials for children whose parents have been diagnosed with cancer and i do not think

that we have any materials that are specifically for children diagnosed with cancer. you might want to check aphon's website that's the association of pediatric hematology/oncology nurses and they may well have

some patient information materials on, on that website where would be a good place to at least ask the question if, if they could give you better direction. so i would, as i said look at cancer.gov at the adolescent young adult,

look at what we have for children when parents have been diagnosed with cancer and then try the aphon website for materials that's typically directed toward children. final thought that i have is that the center

for disease control might have a some information, i am not sure. linda mentioned the understanding cancer theories that actually is part of a larger life science curriculum who are, but that again is aimed at high school science teachers,

it's fairly sophisticated in, in terms of the content, but if you're in, in public health, public health nursing and, and going into a, a high school classroom that might be a good resource for you to use as well.

>> aubrey: thank you. [inaudible] your line is open. >> hello! i'm, i'm just curious to know if you had any cultural specific documentation of how different cultures handle cancer. >> annette: ah, we don't have printed materials

per say. we have done webinars through the ncccp program that is the national cancer institute community clinical oncology program. they have done a series of webinars for their staff on cultural considerations.

we are looking for additional topics for our cancer classroom series and if the audience members think that that might be a useful series for us to undertake, doing a group of webinars on the various cultural groups

that we work with here in the united states and what the cultural considerations are with those groups and cancer that would be something that we would interested in getting some feedback on. there will be an opportunity

at the end of the call. candice will give you some information about completing a, a public comment option and feel free to type in your thoughts and, and desires when it comes to additional trainings for this series.

>> thank you. >> annette: okay. candice is, is giving me the signal that we're just about out of time so let me stop and let me thank you all for the opportunity to answer at least some

of your questions today and thanks linda for really doing a fabulous job kicking off that series. >> candice manor: great and thank you again annette and linda for handling our questions for today and i want

to thank each of you for participation in our seminar today, our first session in our cancer classroom pilot. your feedback is very important to us we continue moving a long plan for this cancer classroom series and we invite your

public comment. these results will let us determine whether or not we move forward offering additional sessions of cancer classroom and this link will be emailed to you following our call today. we hope you'll join us again

on may 17th for our second session in our four session pilot from 2 to 3:30 eastern as we continue to explore the topic of understanding cancer. may session will build upon the topics and concepts that were introduced today

and will focus on cancer treatment and survivor step. thank you all for joining us again and we look forward to see you in may. have a great afternoon. >> thank you

so much participants to use conference call. you may disconnect your line at this time. thank you and have a great day.