Introduction
Code | |
---|---|
Quality of evidence | |
High | A |
Moderate | B |
Low | C |
Very low | D |
Strength of evidence | |
Strong for/against an intervention | 1 |
Weak for/against an intervention | 2 |
Grade of recommendation | Risk/benefit | Quality of evidence | Implications |
---|---|---|---|
1A Strong recommendation High-quality evidence | Benefits clearly outweigh risk and burdens | Consistent evidence from well-performed randomised controlled trials or overwhelming evidence of some other form. Further research is unlikely to change our confidence in the estimate of benefit and risk | Strong recommendation Can apply to most patients in most circumstances without reservation |
1B Strong recommendation Moderate-quality evidence | Benefits clearly outweigh risk and burdens | Evidence from randomised controlled trials with important limitations, or very strong evidence of some other form. Further research is likely to have an impact on our confidence in the estimate of benefit and risk and may change the estimate | Strong recommendation Likely to apply to most patients |
1C Strong recommendation Low-quality evidence | Benefits appear to outweigh risk and burdens | Evidence from observational studies, unsystematic clinical experience, or from randomised, controlled trials with serious flaws. Any estimate of effect is uncertain | Relatively strong recommendation Might change when higher quality evidence becomes available |
2A Weak recommendation High-quality evidence | Benefits closely balanced with risks and burdens | Consistent evidence from well-performed randomised, controlled trials or overwhelming evidence of some other form. Further research is unlikely to change our confidence in the estimate of benefit and risk | Weak recommendation Best action may differ depending on circumstances or patients or societal values |
2B Weak recommendation Moderate-quality evidence | Benefits closely balanced with risks and burdens, some uncertainities in the estimates of benefits, risks and burdens | Evidence from randomised, controlled trials with important limitations, or very strong evidence of some other form. Further research is likely to have an impact on our confidence in the estimate of benefit and risk and may change the estimate | Weak recommendation Alternative approaches likely to be better for some patients under some circumstances |
2C Weak recommendation Low-quality evidence | Uncertainty in the estimates of benefits, risks, and burdens; benefits may be closely balanced with risks and burdens | Evidence from observational studies, unsystematic clinical experience, or from randomised, controlled trials with serious flaws. Any estimate of effect is uncertain | Very weak recommendation Other alternatives may be equally reasonable |
Breast cancer
Primary prevention
Secondary prevention
Mammography
Population | Women aged 40–49 | Women aged 50–69 | Women aged 70–74 |
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Mammography | Individualise, every 2 years 2C |
Routinely, every 2 years
2B |
Routinely, every 2 years
2C |
MRI | Not recommended 2D | Not recommended 2D | Not recommended 2D |
CBE | Not recommended 2C | Not recommended 2C | Not recommended 2C |
BSE | Not recommended 2B | Not recommended 2B | Not recommended 2B |
Magnetic resonance imaging (MRI)
Breast examinations
Cervical cancer
Primary prevention
Secondary prevention
Recommendations
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Routine HPV vaccination is recommended mainly for females aged 11–12 years, but also for females aged 13–18 to catch up those who have not been previously vaccinated or completed their vaccine series (grade 1A). Standard screening for cervical cancer should continue in vaccinated women.
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For women aged 21–29 years, screening with cytology alone every 3 years is recommended (grade 1B). HPV testing should not be used to screen women in this age group.
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Women aged 30–65 years should be screened with the combination of cytology and HPV testing every 5 years, but it is also acceptable the screening with cytology alone every 3 years (grade 1A).
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Women who have undergone total hysterectomy with removal of the cervix and have no history of CIN2+ should not be screened for cervical cancer (grade 1B) (Table 3).Table 3Recommendations for the screening of cervical and prostate cancerCancer sitePopulationRecommended screening methodCervix (women)Aged <21 yearsNo screeningAged 21–29 yearsCytology alone every 3 yearsAged 30–65 yearsHPV and cytology every 5 years (preferred) or Cytology alone every 3 years (acceptable)Aged >65 yearsNo screening if adequate negative prior screening and no history of CIN2+After hysterectomyNo screeningProstate (men)Aged 50–70 yearsPSA ± DREPSA <3 ng/mLRepeat every 1–2 yearsPSA 3–4 ng/mLIndividualised risk assessmentPSA ≥4 ng/mLConsider biopsy or repeat test in 6–12 m
Prostate cancer
Primary prevention
Secondary prevention
Recommendations
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Asymptomatic men with a PSA <3.0 ng/mL who are regularly screened with PSA or are anticipating undergoing annual PSA screening for early detection of prostate cancer may benefit from a discussion of both the risks and benefits of 5α-reductase inhibitors (grade 2B).
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Screening is recommended with PSA with or without DRE for well-informed men aged 50–70 years (grade 1A).
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For men with PSA <3 ng/mL, the test should be repeated every 1–2 years (grade 1B).
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For men whose PSA is >4 ng/mL or those with DRE suspicious for cancer at any PSA level, a biopsy should be considered. If not biopsy is performed, repeat testing in 6–12 months (grade 1B). Percent-free PSA may be assessed in selected patients with PSA values between 4 and 10 ng/mL.
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For PSA levels between 3 and 4 ng/mL, physicians should consider an individualised risk assessment that incorporates other risk factors. These factors include age, family history, ethnicity, DRE or PSA kinetics (grade 2C) Table 3.
Colorectal cancer
Primary prevention [13‐16]
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Consumption of red meat, processed meat and cooked meat that is very well done or has been prepared in direct contact with the source of heat should be moderate (Grade B recommendation).
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A low-fat diet that is high in fibre, fruit and vegetables is advisable (Grade B), although published results are not conclusive. A diet that is high in milk and dairy products is also recommended (Grade B).
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Folate, calcium and vitamin D intake must be adequate (Grade B), but not provided in the form of dietary supplements.
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Antioxidant supplements should not be taken.
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Physical exercise and avoidance of excess weight and obesity must be encouraged to prevent CRC (Grade B).
-
NSAIDs and aspirin should not be taken systematically to prevent CRC (Grade B), nor should hormone treatment be administered (Grade A).
CRC screening recommendations in the average risk population [15] (Table 4)
Recommendation | Evidence |
---|---|
Tests for the detection of hidden blood in faeces (SOH) are a useful tool, and must be considered in CRC screening programmes | A |
Population screening programmes should include a quantitative SOHi (immunohistochemical) detection test with a positive cutoff point that guarantees optimal balance between sensitivity and specificity, based on available endoscopic resources | B |
Opportunistic screening procedures should include SOHi detection tests, although a high-sensitivity SOHg (Guayaco) test could also be used | B |
Flexible sigmoidoscopy is an efficient test that must be considered in CRC screening, at intervals of at least five years | B |
Sigmoidoscopic detection of distal adenomatous polyps requires full colonoscopy (Grade A). This is not the case with hyperplastic polyps | B |
A combined detection strategy using SOHg tests and flexible sigmoidoscopy should not be considered in CRC screening | B |
Colonoscopies should be performed at intervals of at least 10 years | B |
CT-scan colonoscopy should not be considered in CRC screening until more assessments are available on the benefits, costs and acceptability of the technique | B |
-
Tests for the detection of hidden blood in faeces (SOH) are a useful tool, and must be considered in CRC screening programmes (Grade A).
-
Population screening programmes should include a quantitative SOHi (immunohistochemical) detection test with a positive cutoff point that guarantees optimal balance between sensitivity and specificity, based on available endoscopic resources (Grade B).
-
Opportunistic screening procedures should include SOHi detection tests, although a high-sensitivity SOHg (Guayaco) test could also be used (Grade B).
-
Flexible sigmoidoscopy is an efficient test that must be considered in CRC screening, at intervals of at least five years (Grade B).
-
Sigmoidoscopic detection of distal adenomatous polyps requires full colonoscopy (Grade A). This is not the case with hyperplastic polyps (Grade B).
-
A combined detection strategy using SOHg tests and flexible sigmoidoscopy should not be considered in CRC screening (Grade B).
-
Colonoscopies should be performed at intervals of at least 10 years (Grade B).
-
CT-scan colonoscopy should not be considered in CRC screening until more assessments are available on the benefits, costs and acceptability of the technique (Grade B).
Recommendations for population-wide CRC [13, 16] screening programmes (Table 5)
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CRC screening should be offered to all individuals with no risk factors as from the age of 50. In accordance with guidelines established in our milieu (European Union, Spain and its regions), SOH detection tests should be performed every two years in men and women of 50–74 years of age (Grade A).
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Screening tests in population programmes should be based on a quantitative SOHi analysis with a positive cutoff point that guarantees an optimal balance between sensitivity and specificity, depending on the availability of colonoscopies. The choice of other screening tests (annual or biennial SOHg determination, sigmoidoscopy every 5 years or colonoscopy every 10 years) might be warranted if resources are available (Grade B).
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Individuals included in higher-risk groups (polyposis, etc.) must be identified, that they may benefit from specific screening and supervision measures (Grade A).
Recommendation | Evidence |
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CRC screening should be offered to all individuals with no risk factors as from the age of 50. In accordance with guidelines established in our milieu (European Union, Spain and its regions), SOH detection tests should be performed every 2 years in men and women of 50–74 years of age | A |
Screening tests in population programmes should be based on a quantitative SOHi analysis with a positive cutoff point that guarantees an optimal balance between sensitivity and specificity, depending on the availability of colonoscopies. The choice of other screening tests (annual or biennial SOHg determination, sigmoidoscopy every 5 years or colonoscopy every 10 years) might be warranted if resources are available | B |
Individuals included in higher-risk groups (polyposis, etc.) must be identified, that they may benefit from specific screening and supervision measures | A |
Lung cancer
Recommendation | Evidence |
---|---|
Giving up smoking or not taking up the habit | A |
Annual, low-dose CT scans in high-risk groups (individuals of 55–74 years of age who are active smokers or gave up the habit <15 years previously, with a history of at least 30 pack years) | A |