Cancer Screening

Disclaimer: The information on this page is no longer current or being maintained. Updated cancer screening guidelines for newly-arrived refugees are forthcoming. Until new recommendations are made available, clinicians screening refugees for cancer should continue to follow disease-specific US guidelines and observe accepted standards of care.

Immigrants are less likely than the general U.S. population to receive screening tests for cervical, breast and colorectal cancers. 19 Foreign-born populations may be adversely effected due to a large health-care disparity in screening for cancers and may experience worse disease outcomes. 19 Many factors, particularly limited access to care and cultural barriers, account for these disparities. Interestingly, socioeconomic factors, including education and income levels, do not appear to strongly influence the likelihood that refugees will obtain appropriate screening tests. 19

Refugees, as with all U.S. populations, should receive preventive screening according to USPSTF Cancer Screening Guidelines (Table 4). The new-arrival medical screening examination may not be the ideal time to perform invasive medical screening examinations (e.g., pelvic examinations), since many refugees have experienced sexual assault or other traumatic events. However, if an appropriate environment can be created, trust can be established, cultural norms respected, and the risk of additional trauma to the refugee minimized, the visit does present a possible opportunity to provide more invasive cancer screening. Even when invasive examinations are not possible, measures can be taken during new-arrival screening to promote access to future health care and reduce cultural barriers, which may increase cancer screening in refugee populations. Such measures include identifying a primary-care provider, explaining the importance of annual preventive care visits (promoting the message that medical care is for prevention and not just disease), and using professional interpreters to help educate refugees on the benefits of preventive screening in a culturally sensitive manner. In addition, behavioral risks can be addressed, such as avoiding the use of tobacco, alcohol, and other substances (e.g., khat, betel nut) that predispose toward cancer.

Refugee populations are at a disproportionally increased risk for cancers that occur in the developing world, such as cancers of the liver, esophagus, and stomach20 21 22 23 There are no specific guidelines in the United States. for screening for cancers that occur disproportionally in migrants from the developing world, so the clinician must have a low threshold for investigation and early identification of cancers that are common in these populations but not encountered frequently in the United States.

Two extremely prevalent predisposing medical conditions, hepatitis B and H. pylori, are noted here. Hepatitis B is the leading cause of hepatocarcinoma worldwide. Although screening guidelines are under development for hepatocarcinoma in hepatitis B-infected people in the United States, they are not published yet. People with known hepatitis B infection should be referred for possible treatment. In addition, follow-up should be arranged for infected people to be screened on at least a semi-annual basis for early detection of disease by imaging (i.e., right upper quadrant ultrasound) and blood tests (alpha-fetoprotein and aspartate aminotransferase).

Refugees also have extremely high rates of H. pylori infection, which increases risk for gastric cancer.24 Eradication therapy for H. pylori may decrease this risk, especially if administered before the appearance of precancerous lesions. However, experts to date have not recommended screening asymptomatic people in high-risk populations; thus, clinical judgment must be used when working in populations with very high rates of infection and high rates of gastric carcinoma.

Table 4. Summary of USPSTF cancer screening guidelines 18

Summary of USPSTF cancer screening guidelines
Cervical cancer
  • Women should be screened with cervical cytology (Papanicolaou smears) at least every 3 years starting at age 21 or within 3 years of onset of sexual activity (whichever comes first). (Since the sensitivity of a single smear may be 60%-80%, most organizations suggest obtaining annual smears until 2 or 3 consecutive negative results are obtained before spacing screening to every 3 years.)
  • Screening can be discontinued after age 65 in women with previous negative screenings.
  • Screening is not required in women who have had a total hysterectomy for benign disease.
Breast cancer
  • Biennial screening mammography should be offered to women aged 50-74 years of age. Further recommendations are available from the U.S. Preventive Services Task Force 18
Colorectal cancer
  • Men and women ≥ 50 years of age should be screened by one of the following methods:
    • Fecal occult blood testing of 3 consecutive stools annually
    • Flexible sigmoidoscopy or double-contrast barium enema every 5 years
    • Colonoscopy every 10 years

References

  1. U.S. Preventive Services Task Force. Recommendations. Available at: http://www.ahrq.gov/clinic/pocketgd.htmExternal External Web Site Icon. Accessed 7/2, 2012.
  2. Goel MS, Wee CC, McCarthy EP, Davis RB, Ngo-Metzger Q, Phillips RS. Racial and ethnic disparities in cancer screening: The importance of foreign birth as a barrier to care.J Gen Intern Med. 2003;18:1028-1035.
  3. Miller BA, Chu KC, Hankey BF, Ries LA. Cancer incidence and mortality patterns among specific Asian and Pacific Islander populations in the U.S. Cancer Causes and Control 2008;18(3):227-56.
  4. Kem R, Chu KC. Cambodian cancer incidence rates in California and Washington, 1998-2002. Cancer 2007;110(6):1370-5.
  5. Ross JA, Xie Y, Kiffmeyer WR, et. al. Cancer in the Minnesota Hmong population. Cancer 2003;97(12):3076-9.
  6. Nasseri K, Mills PK, Allan M. Asian Pac J Cancer Prev 2007;8(3):405-11.
  7. Verdu EF, Fraser R, Tiberio D, et al. Prevalence of Helicobacter pylori infection and chronic dyspeptic symptoms among immigrants from developing countries and people born in industrialized countriesDigestion. 1996;57:180-5.