Abstract
The incidence of most cancers increases with increasing age. Cancer is the second most common cause of death in older adults after cardiovascular disease. Many common cancers in older adults can be prevented from occurring or can be identified at an early stage and be effectively treated. The prevention and identification of cancer in its early stages, in an attempt to reduce discomfort and disability associated with advanced cancer and cancer treatment, is also a priority. Overscreening for cancer in older adults, can lead to unnecessary diagnostic testing and unnecessary treatment. Both older adults and their healthcare providers need guidance on the appropriate use of cancer prevention and screening interventions. This part one of a two part review addresses special considerations regarding cancer prevention for adults 65 years of age and older. Screening decisions and the impact of limited life expectancy and an older adult’s ability to tolerate cancer treatment are also addressed. Guidance is provided regarding the prevention and early identification of lung, colorectal, bladder and kidney cancer in older adults. The prevention of breast, prostate and female urogenital cancers are addressed in part two.
Introduction.
Life-style changes, especially reduced rates of tobacco use, widespread cancer screening and improved cancer treatment, has led to a decrease in both cancer incidence and cancer mortality in the United States (US). However, because the incidence of many cancers increase with increasing age, cancer incidence remains high in older adults. Cancer is the second most common cause of death in older adults after cardiovascular disease. (1–3) Cancer prevention is important for older adults, not only to reduce mortality, but also to reduce negative effects on quality of life associated with advanced cancer and side effects from cancer treatment.
Cancer prevention efforts are aimed at both preventing cancer from occurring and identifying cancer at an early stage (screening), with the understanding that most early cancers require less extensive treatment and have better outcomes. The prevention and early identification of cancer is an important component of healthy aging. Efforts to prevent cancer and identify early cancers in older adults need to take into consideration cancer epidemiology, the clinical significance of the cancer and the effectiveness, drawbacks and cost of cancer prevention and screening. It is important that clinicians have a clear understanding of the prognosis with and without cancer treatment when discussing cancer screening with older adults. (4)
In this two-part review we will provide information and guidance for healthcare providers regarding the prevention of nine solid organ cancers that are common in older adults. In addition to being common in older adults we chose to address these cancers because there is evidence to support, adjust or avoid prevention efforts in older adults. Part 1 will review lung, colorectal, bladder and kidney cancer prevention. Part 2 will address breast, prostate and female urogenital cancers.
Special Considerations Regarding Cancer Prevention and Cancer Screening in Older Adults.
Limited Life Expectancy
Many cancers occur only after long term exposure to cancer risk factors. Some cancers grow slowly and only become a problem for the patient years after they first occur. For older adult with a limited life expectancy, a late life cancer may not become clinically significant before they die. The term overscreening is applied to identifying such cancers. Recommendations regarding when to stop cancer screening in older adults have historically been based on the patient’s age. Over the last decade, practice guidelines increasingly use life expectancy to guide screening decisions. In addition to age, and comorbid conditions, an older adult’s physical and cognitive function have a significant impact on life expectancy. (5,6) There are several tools that can help providers determine a patient’s life expectancy. Table 1. Unnecessary screening of older adults for cancer is common. (7) Some clinicians may not be aware of the risks of overscreening older adults with limited life expectancy (8)
Table 1.
Tools and resources to help assess cancer risk, determine life expectancy, guide screening recommendations and determine cancer treatment tolerance for older adults.
All of the listed online resources were accessed on 06/01/2020
USPSTF. United States Preventive Services Task Force. ACS. American Cancer Society. AGS. American
Geriatrics Society. CRASH. Chemotherapy Risk Age Scale for High Risk Patients.
Comprehensive Geriatric Assessment, Patient Goals of Care and Shared Decision Making
When deciding whether to recommend cancer screening to an older adult, consideration needs to be given to the patients’ ability to tolerate and benefit from cancer treatment, should a cancer be found. (9,10) There is increasing evidence that age is not the primary determinant of either an older adult’s ability to tolerate or benefit from cancer treatment. (11,12) Frail older adults who have multiple chronic conditions, difficulty maintaining independence, and several geriatric syndromes are at higher risk for adverse outcomes such as mortality or institutionalization and may not have lasting benefits. (13) Comprehensive geriatric assessment (CGA) or other frailty assessment tools help identify older adults who are more likely to tolerate and benefit from cancer treatment. (14,15) Though these tools have been used primarily to assess whether a patient will tolerate cancer treatment, this information may also help guide screening decisions for both healthcare providers and their patients. Many older adults are more concerned about their quality of life than their quantity of life and when the potential benefits and harms of screening for cancer or treating cancer are presented to them, they may choose to forgo the intervention. (16) Shared decision making between healthcare providers and their patients can be facilitated by assessing the patient’s cancer risk, the potential benefits of cancer screening, risks associated with cancer screening, and the ability of the patient to tolerate cancer treatment. Recommendations should be aligned with the patient’s preferences and values. In situations where it is not clear that cancer screening should or should not be recommended, we believe shared decision making between the patient and their healthcare provider may be an appropriate approach. (17)
Lung Cancer
Epidemiology & Clinical Significance
Lung cancer is the leading cause of cancer death for both men and women in the US. Each year, more people die of lung cancer than of colon, breast, and prostate cancers combined. (18) In the US approximately 70% of lung cancers occur in adults 65 years of age or older. Figure 1. (19) The two main types of lung cancer are small cell lung cancer (SCLC) and non-SCLC (NSCLC). NSCLC accounts for approximately 85% of all cases of lung cancer (20). In high income countries, rates in men declined dramatically in the late twentieth century in tandem with a proportional decrease in the male smoking population. African American men have markedly higher rates of lung cancer than non-Hispanic Caucasian or Caucasian men (21). Cigarette smoking is the number one risk factor for lung cancer. In the US it is linked to about 80% to 90% of lung cancer deaths. Using other tobacco products such as cigars or pipes also increases the risk for lung cancer. People who smoke cigarettes are 15 to 30 times more likely to get lung cancer or die from lung cancer than people who do not smoke. There is a direct dose-response relationship between the number of cigarettes smoked and the risk of lung cancer. (22) With the decrease in the prevalence of smoking, lung cancer has become proportionally more frequent among former smokers. Second hand exposure to cigarette smoke is a risk. (23)
Figure 1.
Percentage of New Cases of Cancer in the United States by Age Group. SEER 21 2012–2016, All Races, Both Sexes
Lung cancer is also associated with prolonged exposure to air pollution. (24) Mortality risks rise linearly throughout the full range of exposure to particulate matter with a median aerodynamic diameter of less than 2.5 μm. About 8% of global lung cancer deaths can be attributed to exposure to fine particulate matter alone. The dose–response relationship between lung cancer and ambient particulate matter would be even higher, if only adenocarcinomas of the lung are considered. (25) Numerous occupational exposures, including chemicals, fumes, and radiation, increase lung cancer risk. Radon exposure is also a risk factor for lung cancer. Radon-222 arises naturally from the decay of uranium-238, which is present throughout the earth’s crust. It has a half-life of four days. It diffuses through soil and into the air before decaying. More than 85% of radon-induced lung cancer deaths are among smokers. (26) Even among people who are aware of radon as a health hazard, only a small fraction live in a home that has been tested. The impact of radon exposure on the incidence of lung cancer in older adults is unknown.
Primary Prevention
Lifestyle
Though their risk is higher than the risk for people who never smoked, people who quit smoking have a lower risk of lung cancer than if they had continued to smoke. Quitting smoking at any age can lower the risk of lung cancer. (22) Older adults, regardless of their age, should be encouraged and supported to stop smoking. At this time there is no evidence to support the use of e-cigarettes as a means of quitting smoking in older adults.
Radon
The Surgeon General and US Environmental Protection Agency (EPA) recommend testing for radon and reducing radon in homes that have high levels. Radon reduction steps should be taken if the radon level is confirmed to be 4 picocuries per liter, pCi/L, or higher. (27)
Screening
In June 2011 the results of the National Lung Screening Trial (NLST) showed for the first time that screening a high‐risk population could reduce lung cancer deaths. NLST participant criteria were asymptomatic men and women, 55 to 74 years of age, with a history of at least 30 pack-years of smoking. In this population a 20% relative reduction in mortality from lung cancer was observed with low-dose CT (LDCT) screening. (28) Though there is some variation in the specific recommendations, there is universal consensus that screening should be offered to those with a history of long term, high dose tobacco use. (29) The United States Preventive Services Task Force (USPSTF) and American Cancer Society (ACS) recommendations for lung cancer screening are listed in Table 1 & 2 (30,31)
Table 2.
Primary Prevention and Screening Recommendations for Common Cancers in Older Adults
| Cancer | Primary Prevention | Screening Recommendations |
|---|---|---|
| Lung | Don’t use tobacco products. (23) Check homes for radon gas and take steps to reduce radon when levels are high. (27) |
The USPSTF recommends annual screening for lung cancer with LDCT in adults aged 55 to 80 years of age who have a 30 pack-year smoking history and currently smoke or have quit within the past 15 years. 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 or willingness to have curative lung surgery. (30) The American Cancer Society recommends that clinicians ascertain the smoking status and smoking history of their patients aged 55 to 74 years. Those with access to high‐volume, high‐quality lung cancer screening and treatment centers should initiate a discussion about lung cancer screening with these patients who have at least a 30–pack‐year smoking history, currently smoke, or have quit within the past 15 years, and who are in relatively good health. The mortality reduction benefit should be discussed. Adults who choose to be screened should follow the NLST protocol of annual LDCT screening until they reach age 74 years. (31) |
| Colon | A high fiber diet with ample amounts of fresh fruits and vegetables may be helpful. (36) Don’t use tobacco products. Antiplatelet agents including aspirin are not recommended for older adults. |
The USPSTF recommends that colonoscopy start at age 50 and continue until age 75. For most patients screening is recommended at 10 year intervals. For patients aged 76 to 85, the USPSTF focuses on individual and selective decision-making, and for patients 85 yrs. of age or older recommends against offering screening for CRC. The USPSTF recommends performing FOBT and FIT test every year. FIT-DNA testing can be done every 1 to 3 years. (42) The ACS recommends that adults aged 45 years and older with an average risk of CRC undergo regular screening with either a high‐sensitivity stool‐based test or a structural (visual) examination, depending on patient preference and test availability. The ACS recommends that: 1) average‐risk adults in good health with a life expectancy of more than 10 years continue CRC screening through the age of 75 years; 2) clinicians individualize CRC screening decisions for individuals aged 76 through 85 years based on patient preferences, life expectancy, health status, and prior screening history; and 3) clinicians discourage individuals older than 85 years from continuing CRC screening. (43) |
| Bladder |
Don’t use tobacco products. (52) A diet rich in fruits and vegetables may be helpful. (53) |
The USPSTF concludes that current evidence is insufficient to assess the balance of benefits and harms of screening for bladder cancer in asymptomatic adults, including older adults. (54) The ACS does not include screening for bladder cancer on its list of recommended cancer screening |
| Kidney | Don’t use tobacco products. (56,57) Avoid obesity. (57) Treat hypertension. (58) |
Neither the USPSTF nor the ACS have guidelines regarding kidney cancer screening |
USPSTF: United States Preventive Services Task Force.
LDCT: Low Dose Computer Tomography
NLST: National Lung Screening Trial
Online risk calculator tools provide information on lung cancer risk and the appropriateness of low dose CT screening. (32)
Risks
Lung cancer screening may cause harm, including false positive results which may results in complications associated with additional unnecessary testing and radiation exposure. (33) In the general population the most common complications of CT-guided biopsy of a lung nodule are pneumothorax (15%), pneumothorax requiring a chest tube placement (6.6%) and hemorrhage (1%). (33)
Colorectal Cancer
Epidemiology & Clinical Significance
Colorectal cancer (CRC) is common in older adults. In a cohort of 140,000 patients diagnosed with CRC, the median age was 67 years. (34) In the US approximately 57% of colorectal cancers occur in adults 65 years of age or older. Figure 1. (19) Between 2000 and 2013, CRC incidence rates in adults in the US aged ≥50 years declined by 32%, with the drop being largest for distal tumors in people aged ≥65 years. CRC death rates decreased by 34% among individuals aged ≥50 years between 2000 and 2014, but increased by 13% in those aged <50 years. (35) Trends in both CRC incidence and mortality are difficult to interpret because of the large number of variables involved. More extensive screening contributes to a lower incidence as precancerous lesions are identified and removed. Fewer smokers reduces CRC incidence, while increasing rates of obesity increases incidence. Early identification and treatment reduces mortality.
High consumption of red and processed meat and alcoholic beverages and low consumption of foods containing dietary fiber, increase the risk of CRC. Obesity increases the risk of CRC, while physical activity protects against CRC. (36) Additional risk factors for CRC include a family history of CRC and a personal history of CRC or colon polyps. Previous negative colonoscopies reduce the risk of CRC. The National Cancer Institute has an online risk calculator for colorectal cancer. Table 1.
Primary Prevention
Lifestyle
Though the impact of life-style interventions on reducing CRC incidence, especially in older adults are difficult to quantify, increase in physical activity, reduction or cessation of alcohol consumption, stopping cigarette smoking, increasing dietary fiber and consuming a diet high in fresh fruits and vegetables, promote overall good health and may reduce CRC risk. (36)
Antiplatelet agents
Though there is evidence to suggest that antiplatelet agents including aspirin prevent CRC, (37) more recent data from the Aspirin in Reducing Events in the Elderly (ASPREE) study indicated that 100mg of enteric coated aspirin increased cancer related mortality and especially colon cancer death in older adults. (38) There is insufficient evidence to recommend the use of antiplatelet agents to prevent CRC in older adults.
Screening
Options for CRC screening are: guaiac‐based fecal occult blood testing (gFOBT); fecal immunochemical testing (FIT); multitarget stool DNA testing (FIT-DNA); colonoscopy; computed tomography colonography and flexible sigmoidoscopy.
Identification of pre-cancerous lesions
Colon imaging studies and stool testing which leads to colon imaging studies, prevent colon cancers by identifying non-cancerous polyps considered to be high risk. These lesions can be removed prior to becoming a cancer. Though colonoscopy has been demonstrated to have the greatest impact on CRC incidence, sigmoidoscopy and FIT have also been demonstrated to have a significant impact. (39)
Colonoscopy & Sigmoidoscopy
Colonoscopy has been demonstrated to reduce CRC mortality. (40) However because the data were observational, it is possible that lifestyle changes such as decreased smoking or dietary changes explain the observed reduction in CRC mortality. Both colonoscopy and sigmoidoscopy have been demonstrated to be more effective at reducing CRC mortality than annual FIT for patients 75–79 yrs. of age. (41) The USPSTF and ACS recommendations for CRC screening are listed in Table 1 & 2. (42, 43)
Fecal testing
Though evidence suggests that colon imaging is the best means of preventing CRC mortality in older adults, fecal testing may also be used to screen for CRC. FIT has largely replaced gFOBT due to both higher sensitivity and specificity. FIT-DNA is more sensitive but less specific and more costly than FIT. (44) When discussing fecal testing with older adults who are frail or have a limited life-expectancy, shared decision making is important. There is little benefit in doing fecal testing if the patient is not willing or is not a candidate for a colonoscopy; though some patients may be willing to have and may benefit from a sigmoidoscopy. (45)
Risks
There are significant risks associated with colonoscopy especially in the older adults. (46) The rate of complications in patients 65 years or older included perforation (1%), GI bleed (6.3%), CV/pulmonary complications (19%) and death (1%). Octogenarians experienced higher risk of perforation (1.6%). (46) In addition, some older adults will have difficulty tolerating the preparation for a colonoscopy, including electrolyte abnormalities. (47) Although fecal testing is less invasive, depending on a variety of patient characteristics, false positive results occur between 45–70% of the time; which leads to more invasive procedures. (48) Overscreening as high as 28% has been reported for older adults. (49) Tools such as ePrognosis can help guide decisions regarding the appropriate use of CRC screening for older adults. (50)
Bladder Cancer
Epidemiology & Clinical Significance
Bladder cancer is the second most common urologic malignancy in the US. (19) In the US approximately 74% of bladder cancers occur in adults 65 years of age or older. Figure 1. (19) The median age at time of diagnosis is approximately 70 years and incidence does not peak until patients are in their 80’s. Risk factors for bladder cancer include increasing age, male sex, and smoking cigarettes. People who smoke have a four times increased risk of developing bladder cancer compared to non-smokers. (51)
Primary Prevention
Lifestyle
Smoking cessation for 1–4 years results in a 30% decrease in the risk of bladder cancer. When someone has stopped smoking for more than 10 years, their risk of developing bladder cancer is similar to nonsmokers. (52) While there have been no studies looking specifically at the impact of smoking cessation on bladder cancer risk in older adults, those with at least a five year life expectancy are likely to benefit. A single meta-analysis demonstrated that increased fruit and vegetable intake was associated with a decreased risk of bladder cancer. (53) The impact of dietary interventions on bladder cancer incidence in older adults is not clear.
Screening
The USPSTF concludes that current evidence is insufficient to assess the balance of benefits and harms of screening for bladder cancer in asymptomatic adults, including older adults. (54) Regardless of age, neither urinalysis nor cystoscopy are recommended as a means of screening for bladder cancer.
Risks
Risks from inappropriate screening include anxiety regarding test results, unnecessary surgery and associated complications.
Kidney Cancer
Epidemiology & Clinical Significance
Kidney cancer is the third most common urologic malignancy and the 8th most common cancer in the US. More than 400,000 new cases of kidney cancer were diagnosed worldwide in 2018. (55) The median age at diagnosis is 64 years and the median age at death from kidney cancer is 71 years. In the US approximately 50% of kidney cancers occur in adults 65 years of age or older. Figure 1. (19) Known risk factors for the development of kidney cancer include increasing age, obesity, hypertension, family history of kidney cancer, smoking, occupational exposures (e.g. trichloroethylene), and renal failure.
Primary Prevention
Lifestyle
Observational data indicate a strong association between cigarette smoking and obesity and the development of kidney cancer. (56, 57) The impact of lifestyle changes on the incidence of kidney cancer in older adults is unknown. Though hypertension is a risk factor for kidney cancer, (58) the impact of lowering blood pressure on the incidence of kidney cancer in older adults is also unknown.
Screening
Screening for kidney cancer is only recommended in the small number of patients with hereditary kidney cancer syndromes. Excluding these patients, there are no specific screening recommendations. Routine urinalysis should not be used to screen for kidney cancer.
Risks
Risks from inappropriate screening include anxiety regarding test results, unnecessary surgery and associated complications.
Summary
Cancer is common in older adults. It is important that healthcare providers educate their patients regarding their cancer risks and where appropriate recommend interventions to both prevent and screen for cancer. An older adult’s life expectancy is a better determinant of when to stop screening for cancer than the patient’s age. Interventions that have not been shown to provide benefit for older adults should be avoided.
Acknowledgements:
Sponsor’s Role. Not applicable
Funding: Not applicable
Footnotes
Conflicts of Interest. None of the authors report any conflicts of interests regarding this manuscript.
References
- (1).All Cancer Sites Combined SEER Incidence Rates by Age at Diagnosis, 2012-2016. https://seer.cancer.gov/explorer/application.php?site=1&data_type=1&graph_type=3&compareBy=sex&chk_sex_1=1&chk_race_1=1&chk_data_type_1=1&advopt_precision=1&showDataFor=race_1_and_data_type_1 (accessed 06/01/2020)
- (2).DeSantis CE, Miller KD, Dale W, et al. Cancer statistics for adults aged 85 years and older. CA Cancer J Clin. 2019;69(6):452–467. doi: 10.3322/caac.21577. [DOI] [PMC free article] [PubMed] [Google Scholar]
- (3).Cancer deaths by age: world. https://ourworldindata.org/grapher/cancer-deaths-by-age (accessed 06/01/2020)
- (4).Harris RP, Wilt TJ, Qaseem A. High Value Care Task Force of the American College of Physicians. A value framework for cancer screening: advice for high-value care from the American College of Physicians. Ann Intern Med. 2015;162(10):712–717. doi: 10.7326/M14-2327. [DOI] [PubMed] [Google Scholar]
- (5).Schonberg MA, Davis RB, McCarthy EP, Marcantonio ER. External validation of an index to predict up to 9-year mortality of community-dwelling adults aged 65 and older. J Am Geriatr Soc. 2011;59(8):1444–1451. [DOI] [PMC free article] [PubMed] [Google Scholar]
- (6).Lansdorp-Vogelaar I, Gulati R, Mariotto AB, et al. Personalizing age of cancer screening cessation based on comorbid conditions: model estimates of harms and benefits. Ann Intern Med. 2014;161(2):104–112. doi: 10.7326/M13-2867. [DOI] [PMC free article] [PubMed] [Google Scholar]
- (7).Drazer MW, Prasad SM, Huo D, et al. National trends in prostate cancer screening among older American men with limited 9-year life expectancies: evidence of an increased need for shared decision making. Cancer. 2014;120(10):1491–1498. doi: 10.1002/cncr.28600. [DOI] [PubMed] [Google Scholar]
- (8).Schoenborn NL, Massare J, Park R, et al. Clinician Perspective on Overscreening for Cancer in Older Adults With Limited Life Expectancy. J Am Geriatr Soc. 2020. doi: 10.1111/jgs.16415. [DOI] [PMC free article] [PubMed] [Google Scholar]
- (9).Aaldriks AA, Maartense E, le Cessie S, et al. Predictive value of geriatric assessment for patients older than 70 years, treated with chemotherapy. Crit Rev Oncol Hematol. 2011;79:205–212 [DOI] [PubMed] [Google Scholar]
- (10).Williams GR, Mackenzie A, Magnuson A, et al. Comorbidity in older adults with cancer. J Geriatr Oncol. 2016;7(4):249–257. doi: 10.1016/j.jgo.2015.12.002. [DOI] [PMC free article] [PubMed] [Google Scholar]
- (11).Korc-Grodzicki B, Holmes HM, Shahrokni A. Geriatric assessment for oncologists. Cancer Biol Med. 2015;12(4):261–274. doi: 10.7497/j.issn.2095-3941.2015.0082. [DOI] [PMC free article] [PubMed] [Google Scholar]
- (12).Dumas L, Ring A, Butler J, Kalsi T, Harari D, Banerjee S. Improving outcomes for older women with gynaecological malignancies. Cancer Treat Rev. 2016;50:99–108. doi: 10.1016/j.ctrv.2016.08.007. [DOI] [PMC free article] [PubMed] [Google Scholar]
- (13).Pamoukdjian F, Liuu E, Caillet P, et al. How to Optimize Cancer Treatment in Older Patients: An Overview of Available Geriatric Tools. Am J Clin Oncol. 2019;42(2):109–116. doi: 10.1097/COC.0000000000000488. [DOI] [PubMed] [Google Scholar]
- (14).Kalsi T, Babic-Illman G, Ross PJ, et al. The impact of comprehensive geriatric assessment interventions on tolerance to chemotherapy in older people. Br J Cancer. 2015;112(9):1435–1444. doi: 10.1038/bjc.2015.120. [DOI] [PMC free article] [PubMed] [Google Scholar]
- (15).Mohile SG, Epstein RM, Hurria A, et al. Communication With Older Patients With Cancer Using Geriatric Assessment: A Cluster-Randomized Clinical Trial From the National Cancer Institute Community Oncology Research Program. JAMA Oncol. 2019;7:1–9. doi: 10.1001/jamaoncol.2019.4728. [DOI] [PMC free article] [PubMed] [Google Scholar]
- (16).Shrestha A, Martin C, Burton M, Walters S, Collins K, Wyld L. Quality of life versus length of life considerations in cancer patients: A systematic literature review. Psychooncology. 2019;28(7):1367–1380. [DOI] [PMC free article] [PubMed] [Google Scholar]
- (17).American Medical Association. Getting the most for our health care dollars: shared decision making. American Medical Association, Chicago IL; 2011www.ama-assn.org/resources/doc/health-care-costs/shared-decision-making.pdf. (accessed 11/04/19) [Google Scholar]
- (18).Key Statistics for Lung Cancer. https://www.cancer.org/content/cancer/en/cancer/lung-cancer/about/key-statistics.html (accessed 06/01/2020)
- (19).National Cancer Institute. Surveillance, Epidemiology and End-Results (SEER) Program. Cancer Stat Facts. https://seer.cancer.gov/statfacts/ (accessed 04/17/2020)
- (20).Molina JR, Yang P, Cassivi SD, Schild SE, Adjei AA. Non-small cell lung cancer: epidemiology, risk factors, treatment, and survivorship. Mayo Clin Proc. 2008;83(5):584–594 [DOI] [PMC free article] [PubMed] [Google Scholar]
- (21).Torre LA, Siegel RL, Jemal A. Lung Cancer Statistics. Adv Exp Med Biol. 2016;893:1–19. [DOI] [PubMed] [Google Scholar]
- (22).de Groot P, Munden RF. Lung cancer epidemiology, risk factors, and prevention. Radiol Clin North Am. 2012;50(5):863–876. [DOI] [PubMed] [Google Scholar]
- (23).CDC. What Are the Risk Factors for Lung Cancer? Available from: https://www.cdc.gov/cancer/lung/basic_info/risk_factors.htm. (06/01/2020)
- (24).Hamra GB, Laden F, Cohen AJ, Raaschou-Nielsen O, Brauer M, Loomis D. Lung Cancer and Exposure to Nitrogen Dioxide and Traffic: A Systematic Review and Meta-Analysis. Environ Health Perspect. 2015;123(11):1107–1112. doi: 10.1289/ehp.1408882. [DOI] [PMC free article] [PubMed] [Google Scholar]
- (25).Fajersztajn L, Veras M, Barrozo LV, Saldiva P. Air pollution: a potentially modifiable risk factor for lung cancer. Nat Rev Cancer. 2013;13(9):674–678 [DOI] [PubMed] [Google Scholar]
- (26).Lantz PM, Mendez D, Philbert MA. Radon, smoking, and lung cancer: the need to refocus radon control policy. Am J Public Health. 2013;103(3):443–447 [DOI] [PMC free article] [PubMed] [Google Scholar]
- (27).United States Surgeon General’s Health Advisory on Radon. http://www.adph.org/radon/assets/surgeon_general_radon.pdf (06/01/2020)
- (28).National Lung Screening Trial Research Team, Aberle DR, Adams AM, Berg CD, et al. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med. 2011;365(5):395–409. [DOI] [PMC free article] [PubMed] [Google Scholar]
- (29).Arenberg D Update on screening for lung cancer. Transl Lung Cancer Res. 2019. ;8(Suppl 1):S77–S87. doi: 10.21037/tlcr.2019.03.01. [DOI] [PMC free article] [PubMed] [Google Scholar]
- (30).Moyer VA US Preventive Services Task Force. Screening for lung cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2014;160(5):330–338. [DOI] [PubMed] [Google Scholar]
- (31).Wender R, Fontham ET, Barrera E Jr, et al. , American Cancer Society lung cancer screening guidelines. CA Cancer J Clin. 2013;63(2):107–117 [DOI] [PMC free article] [PubMed] [Google Scholar]
- (32).Memorial Sloan Kettering Cancer Center. Lung Cancer Screening Decision Tool. http://nomograms.mskcc.org/Lung/Screening.aspx (accessed 06/01/20)
- (33).Wiener RS, Schwartz LM, Woloshin S, Welch HG. Population-based risk for complications after transthoracic needle lung biopsy of a pulmonary nodule: an analysis of discharge records. Ann Intern Med. 2011;155(3):137–144. doi: 10.7326/0003-4819-155-3-201108020-00003. [DOI] [PMC free article] [PubMed] [Google Scholar]
- (34).Siegel RL, Miller KD, Fedewa SA, et al. Colorectal cancer statistics, 2017. CA Cancer J Clin. 2017;67(3):177–193. [DOI] [PubMed] [Google Scholar]
- (35).Brenner H, Chang-Claude J, Seiler CM, Rickert A, Hoffmeister M. Protection from colorectal cancer after colonoscopy: a population-based, case–control study. Ann Intern Med. 2011;154(1):22–30 [DOI] [PubMed] [Google Scholar]
- (36).World Cancer Research Fund/American Institute for Cancer Research. WCRF/AICR Systematic literature review - continuous update project report. The associations between food, nutrition and physical activity and the risk of Colorectal Cancer. 2010. http://www.dietandcancerreport.org/cancer_resource_center/cup_reports.php. (accessed 06/01/20)
- (37).Whitlock EP, Williams SB, Burda BU, Feightner A, Beil T. Aspirin Use in Adults: Cancer, All-Cause Mortality, and Harms: A Systematic Evidence Review for the U.S. Preventive Services Task Force. Rockville (MD): Agency for Healthcare Research and Quality (US); 2015. Sep. Report No.: 13–05193-EF-1. U.S. Preventive Services Task Force Evidence Syntheses, formerly Systematic Evidence Reviews. [PubMed] [Google Scholar]
- (38).McNeil JJ, Nelson MR, Woods RL, et al. ASPREE Investigator Group. Effect of Aspirin on All-Cause Mortality in the Healthy Elderly. N Engl J Med 2018;379(16):1519–1528. doi: 10.1056/NEJMoa1803955. Epub 2018 Sep 16. PMID: [DOI] [PMC free article] [PubMed] [Google Scholar]
- (39).Buskermolen M, Cenin DR, Helsingen LM, et al. Colorectal cancer screening with faecal immunochemical testing, sigmoidoscopy or colonoscopy: a microsimulation modelling study. BMJ. 2019;367:l5383. doi: 10.1136/bmj.l5383. [DOI] [PMC free article] [PubMed] [Google Scholar]
- (40).Nishihara R, Wu K, Lochhead P, et al. Long-term colorectal-cancer incidence and mortality after lower endoscopy. N Engl J Med. 2013;369(12):1095–1105. doi: 10.1056/NEJMoa1301969. [DOI] [PMC free article] [PubMed] [Google Scholar]
- (41).Helsingen LM, Vandvik PO, Jodal HC, et al. Colorectal cancer screening with faecal immunochemical testing, sigmoidoscopy or colonoscopy: a clinical practice guideline BMJ 2019;367:l5515. doi: 10.1136/bmj.l5515. [DOI] [PubMed] [Google Scholar]
- (42).Bibbins-Domingo K, Grossman DC, Curry SJ, et al. Screening for colorectal cancer: US Preventive Services Task Force recommendation statement. JAMA. 2016;315(23):2564–2575. doi: 10.1001/jama.2016.5989. Erratum in: JAMA 2016;316(5):545. Erratum in: JAMA. 2017 ;317(21):2239. [DOI] [PubMed] [Google Scholar]
- (43).Wolf AMD, Fontham ETH, Church TR, et al. Colorectal cancer screening for average-risk adults: 2018 guideline update from the American Cancer Society. CA Cancer J Clin. 2018;68(4):250–281. doi: 10.3322/caac.21457. [DOI] [PubMed] [Google Scholar]
- (44).Song LL, Li YM. Current noninvasive tests for colorectal cancer screening: An overview of colorectal cancer screening tests. World J Gastrointest Oncol. 2016; 8(11): 793–800. [DOI] [PMC free article] [PubMed] [Google Scholar]
- (45).Lin G, Feng Z, Liu H, et al. Mass screening for colorectal cancer in a population of two million older adults in Guangzhou, China. Sci Rep. 2019;9(1):10424. doi: 10.1038/s41598-019-46670-2. [DOI] [PMC free article] [PubMed] [Google Scholar]
- (46).Day LW, Kwon A, Inadomi JM, Walter LC, Somsouk M. Adverse events in older patients undergoing colonoscopy: a systematic review and meta-analysis. Gastrointest Endosc. 2011;74(4):885–896 [DOI] [PMC free article] [PubMed] [Google Scholar]
- (47).Ho JM, Gruneir A, Fischer HD, et al. Serious events in older Ontario residents receiving bowel preparations for outpatient colonoscopy with various comorbidity profiles: a descriptive, population-based study. Can J Gastroenterol. 2012;26(7):436–440. [DOI] [PMC free article] [PubMed] [Google Scholar]
- (48).de Klerk CM, Vendrig LM, Bossuyt PM, Dekker E. Participant-Related Risk Factors for False-Positive and False-Negative Fecal Immunochemical Tests in Colorectal Cancer Screening: Systematic Review and Meta-Analysis. Am J Gastroenterol. 2018. ;113(12):1778–1787. doi: 10.1038/s41395-018-0212-7 [DOI] [PMC free article] [PubMed] [Google Scholar]
- (49).Schonberg MA, Breslau ES, Hamel MB, Bellizzi KM, McCarthy EP. Colon cancer screening in U.S. adults aged 65 and older according to life expectancy and age. J Am Geriatr Soc. 2015;63(4):750–756. doi: 10.1111/jgs.13335. [DOI] [PubMed] [Google Scholar]
- (50).ePrognosis colo-rectal screening survey. http://cancerscreening.eprognosis.org/screening/ (accessed 06/01/2020)
- (51).Freedman ND, Silverman DT, Hollenbeck AR, Schatzkin A, Abnet CC. Association between smoking and risk of bladder cancer among men and women. JAMA. 2011;306(7):737–745 [DOI] [PMC free article] [PubMed] [Google Scholar]
- (52).Sosnowski R, Bjurlin MA, Verze P, et al. Role of cigarette smoking in urological malignancies and clinical interventions for smoking cessation. Cent European J Urol. 2016;69(4):366–369 [DOI] [PMC free article] [PubMed] [Google Scholar]
- (53).Al-Zalabani AH, Stewart KF, Wesselius A, Schols AM, Zeegers MP. Modifiable risk factors for the prevention of bladder cancer: a systematic review of meta-analyses. Eur J Epidemiol. 2016;31(9):811–855 [DOI] [PMC free article] [PubMed] [Google Scholar]
- (54).USPSTF. Bladder Cancer in Adults: Screening https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/bladder-cancer-in-adults-screening?ds=1&s=bladder%20cancer (accessed 06/01/209)
- (55).Bray F, Ferlay J, Soerjomataram I, et al. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2018;68(6):394–424. doi: 10.3322/caac.21492. [DOI] [PubMed] [Google Scholar]
- (56).Freedman ND, Silverman DT, Hollenbeck AR, Schatzkin A, Abnet CC. Association between smoking and risk of bladder cancer among men and women. JAMA. 2011;306(7):737–745. doi: 10.1001/jama.2011.1142. [DOI] [PMC free article] [PubMed] [Google Scholar]
- (57).Al-Zalabani AH, Stewart KF, Wesselius A, Schols AM, Zeegers MP. Modifiable risk factors for the prevention of bladder cancer: a systematic review of meta-analyses. Eur J Epidemiol. 2016;31(9):811–851. doi: 10.1007/s10654-016-0138-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- (58).Sanfilippo KM, McTigue KM, Fidler CJ, et al. Hypertension and obesity and the risk of kidney cancer in 2 large cohorts of US men and women. Hypertension. 2014. ;63(5):934–941. doi: 10.1161/HYPERTENSIONAHA.113.02953. [DOI] [PMC free article] [PubMed] [Google Scholar]