2.2 Primary Prevention, Vaccination, Chemoprevention & Risk-Reducing Surgery
Key Takeaways
HPV vaccination is routinely recommended at ages 11 to 12, may start at age 9, and is given as a two-dose series when initiated before the 15th birthday and a three-dose series when initiated at or after age 15 or in immunocompromised patients.
Tobacco cessation is most effective when behavioral counseling is combined with pharmacotherapy; varenicline and combination nicotine replacement produce the highest quit rates.
Tamoxifen, raloxifene, and the aromatase inhibitors anastrozole and exemestane reduce invasive breast cancer incidence in high-risk women by roughly 40% to 65%, with tamoxifen the only option approved for premenopausal risk reduction.
Risk-reducing salpingo-oophorectomy is recommended at ages 35 to 40 for BRCA1 carriers and 40 to 45 for BRCA2 carriers after childbearing, and reduces ovarian cancer risk by more than 80%.
Aspirin reduces colorectal cancer incidence in Lynch syndrome carriers, and finasteride or dutasteride reduce overall prostate cancer detection but require explicit shared decision-making.
2.2 Primary Prevention, Vaccination, Chemoprevention & Risk-Reducing Surgery
Blueprint focus: ONCC Domain I.A — prevention arm. Screening detects existing disease; primary prevention stops it from arising. The exam tests vaccination schedules, cessation pharmacotherapy, chemoprevention eligibility, and the ages at which risk-reducing surgery is offered.
1. Tobacco Cessation
Tobacco causes more cancer deaths than any other modifiable exposure, so cessation is the single highest-yield preventive act an oncology APRN performs — including in patients already diagnosed with cancer, where continued smoking worsens treatment toxicity, wound healing, second-primary risk, and survival.
Use the 5 A's: Ask, Advise, Assess, Assist, Arrange. Brief advice alone raises quit rates modestly; advice plus pharmacotherapy plus behavioral support roughly triples them.
| Agent | Typical regimen | Key counseling point |
|---|---|---|
| Varenicline | 0.5 mg daily × 3 days, 0.5 mg BID × 4 days, then 1 mg BID for 12 weeks | Highest single-agent quit rate; start 1 week before quit date; counsel on vivid dreams and nausea |
| Combination nicotine replacement | Long-acting patch plus a short-acting form (gum, lozenge, inhaler, nasal spray) | Combination beats patch alone; match patch strength to cigarettes per day |
| Bupropion SR | 150 mg daily × 3 days then 150 mg BID | Avoid with seizure disorder or eating disorder history; useful when depression coexists |
Extend pharmacotherapy beyond 12 weeks when relapse risk remains high, and treat relapse as an expected part of the process rather than a failure.
2. Vaccination Against Oncogenic Infections
HPV vaccination
The 9-valent HPV vaccine prevents infection with the types responsible for nearly all cervical cancers and most oropharyngeal, anal, vulvar, vaginal, and penile squamous cancers.
- Routine age: 11 to 12 years, and vaccination may begin at age 9.
- Two-dose schedule (0 and 6 to 12 months): when the first dose is given before the 15th birthday.
- Three-dose schedule (0, 1 to 2, and 6 months): when the series starts at age 15 or older, or at any age in patients who are immunocompromised, including those with HIV or after transplant.
- Catch-up is recommended through age 26. Between ages 27 and 45, vaccination is a shared clinical decision — benefit is smaller because many adults have already been exposed.
- Vaccination does not replace cervical screening.
Hepatitis B vaccination
Universal infant vaccination plus adult vaccination through age 59 (and for at-risk adults 60 and older) prevents chronic infection and therefore hepatocellular carcinoma. Patients about to receive B-cell–depleting therapy such as rituximab must be screened for hepatitis B surface antigen and core antibody before treatment because of reactivation risk.
Helicobacter pylori eradication
Test-and-treat strategies in high-incidence populations and in patients with a first-degree relative with gastric cancer reduce gastric adenocarcinoma incidence.
3. Pharmacologic Chemoprevention
Chemoprevention means giving a drug to a person without cancer to lower the chance they develop it. Eligibility rests on a quantified risk estimate, and every conversation must weigh absolute benefit against the drug's own harms.
Breast cancer
Candidates are women aged 35 and older with a 5-year Gail-model risk of at least 1.67%, a history of lobular carcinoma in situ or atypical hyperplasia, or a strong family history.
| Agent | Population | Risk reduction | Principal harms |
|---|---|---|---|
| Tamoxifen 20 mg daily × 5 years | Pre- or postmenopausal | ~50% reduction in invasive ER-positive breast cancer | Endometrial carcinoma, venous thromboembolism, cataracts, vasomotor symptoms |
| Raloxifene 60 mg daily × 5 years | Postmenopausal only | Somewhat less effective than tamoxifen for invasive disease | Venous thromboembolism, hot flashes; no increase in endometrial cancer |
| Anastrozole or exemestane | Postmenopausal only | ~50% to 65% reduction | Arthralgia, accelerated bone loss requiring DEXA monitoring |
Because tamoxifen is the only option that works before menopause, a premenopausal patient with atypical hyperplasia who is offered "an aromatase inhibitor for prevention" is a classic distractor.
Colorectal cancer
Daily aspirin reduces long-term colorectal cancer incidence, and the effect is best established in Lynch syndrome, where regular aspirin has been shown to lower colorectal cancer incidence in randomized follow-up. Aspirin is not recommended as universal population chemoprevention because gastrointestinal and intracranial bleeding offset benefit in average-risk adults.
Prostate cancer
5-alpha-reductase inhibitors (finasteride, dutasteride) reduce the overall detection of prostate cancer but are not FDA-approved for prevention, and their use requires shared decision-making about the relative-risk trade-offs and PSA interpretation, since these drugs roughly halve measured PSA.
4. Risk-Reducing Surgery
Surgery is the most effective risk reduction available to carriers of high-penetrance variants, and its timing is heavily tested.
| Procedure | Indication | Recommended timing | Effect |
|---|---|---|---|
| Risk-reducing salpingo-oophorectomy (RRSO) | BRCA1 | Ages 35 to 40, after childbearing | Reduces ovarian, fallopian tube, and peritoneal cancer risk by more than 80% |
| RRSO | BRCA2 | Ages 40 to 45 (ovarian cancer onset is later) | Same magnitude of ovarian risk reduction |
| Risk-reducing mastectomy | BRCA1/2, TP53, PTEN, prior chest radiation before age 30 | Individualized; elective | Reduces breast cancer risk by more than 90% |
| Total hysterectomy with bilateral salpingo-oophorectomy | Lynch syndrome | After childbearing, typically around age 40 to 45 | Eliminates endometrial and ovarian cancer risk |
| Total proctocolectomy or colectomy | Familial adenomatous polyposis | Late adolescence to early adulthood, once polyp burden is unmanageable endoscopically | Prevents an otherwise near-certain colorectal cancer |
| Prophylactic thyroidectomy | RET variant in multiple endocrine neoplasia type 2 | Age determined by the specific RET codon | Prevents medullary thyroid carcinoma |
Premenopausal RRSO causes surgical menopause. Counsel proactively about vasomotor symptoms, bone density loss, cardiovascular risk, and sexual health, and discuss short-term hormone therapy for patients without a breast cancer history, since the balance of evidence supports it up to the natural age of menopause in that setting.
5. Structuring the Prevention Visit
- Confirm risk category from Section 2.1 before selecting an intervention.
- Deliver cessation advice with pharmacotherapy at every encounter with a current tobacco user.
- Verify vaccination status against the age-appropriate HPV and hepatitis B schedule.
- Quantify breast cancer risk with a validated model before discussing chemoprevention, and document the absolute benefit and absolute harm.
- For carriers, name the specific surgery and its recommended age window, and coordinate fertility discussion before any procedure that ends reproductive capacity.
A 14-year-old presents for a well visit and has never received HPV vaccine. Which schedule should the nurse practitioner order?
A single dose now, with no further doses required at any age
No vaccination, because HPV vaccine is only indicated after the onset of sexual activity
A three-dose series at 0, 1 to 2, and 6 months, because three doses are required for everyone under 18
A two-dose series given at 0 and 6 to 12 months, because the first dose is given before the 15th birthday
A 41-year-old premenopausal woman with biopsy-proven atypical ductal hyperplasia and a 5-year Gail model risk of 2.4% asks about medication to lower her breast cancer risk. Which agent is appropriate?
Anastrozole 1 mg daily for 5 years
Exemestane 25 mg daily for 5 years
Raloxifene 60 mg daily for 5 years
Tamoxifen 20 mg daily for 5 years
A 36-year-old woman with a germline BRCA1 pathogenic variant has completed childbearing and asks when risk-reducing salpingo-oophorectomy should be performed and what benefit to expect.
Between ages 35 and 40, with a reduction in ovarian, fallopian tube, and peritoneal cancer risk exceeding 80%
Only after age 55, because earlier surgery provides no measurable ovarian cancer benefit
Between ages 40 and 45, which is the recommended window for BRCA1 carriers
Never, because intensified transvaginal ultrasound and CA-125 surveillance is equally effective
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