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 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?
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.