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Cancer Screening Controversies: Making an Informed Decision

December 2009

Cancer screening has always been an essential part of primary care and your annual visit to the doctor. It’s clear that screening detects cancers in their early stages and saves lives. How many lives screening saves and the risks involved have come under intense scrutiny lately. The recent changes in the recommendations regarding breast cancer screening highlight these uncertainties and have ignited debate and in some cases outrage.

The U.S. Preventive Services Task Force (USPSTF) is a governmental body that has been making recommendations regarding all types of health maintenance and screening measures. The panel’s recent recommendations on breast cancer screening are markedly different from common practice. The USPSTF now recommends against using routine mammography in women aged 40-49. Other medical authorities such as the American Cancer Society, American College of Obstetrics and Gynecology and individual practitioners disagree.

The panel took into consideration the fact that there are a large number of false positive mammograms that lead to biopsies and it takes about 2000 screening mammograms to catch one case of breast cancer, the so called “number needed to screen.” There are a significant number of cases of “false positives” or cases that a mammogram might suggest that breast cancer is present and after a biopsy and much anxiety the results show no signs of cancer. It’s clear and without much debate that a better screening technique which provides less discomfort for women is needed.

A large proportion of breast cancers occur between 40 and 49 and in women that do not have a family history of breast cancer or other risk factors. These are some of the characteristics of a population where screening can make the greatest difference and many ask why discourage it? Many cases of breast cancer are diagnosed by women when they perform their own breast exam and notice a lump. They subsequently bring it to their doctor’s attention and have a mammogram and biopsy done. The recommendations for regular self breast exams saving lives have been mixed and without adequate evidence. I think that the more aware you are of your body through regular exams the better you’ll be able to detect concerning changes.

The new recommendations were based on studies of large populations of women. An individual woman’s risk for cancer can never be calculated with 100% accuracy. I think that assessing your own level of comfort with the uncertainty associated with both screening and not screening will help you make an informed decision about whether or not to follow the new guidelines. The uncertainty of having an invasive diagnostic test that turns out to be a false positive versus potentially having a cancer, not screening for it and perhaps finding it at a later stage need to be weighed against each other.

If the new USPSTF recommendations for breast cancer screening become the standard there will be cases of breast cancer that could have been caught earlier by screening. If we continue screening women between 40—49 years there will be biopsies done in the absence of disease. The choice for screening should be left up to you.

Cervical cancer screening has also been scrutinized by the USPSTF with the last set of official recommendations in 2003. There has been some debate about recommending less frequent PAP smears because of evidence suggesting that many cases of early cervical cancer resolve on their own and don’t necessarily require some of the biopsies and treatments that are applied when the early stages of cervical cancer are detected.

Recommendations by the USPSTF for colon cancer screening are different and more conservative than other medical authorities such as the American Cancer Society and American College of Gastroenterology.

Prostate cancer screening with the PSA blood test remains one of the most controversial cancer screening tests because of a large proportion (up to one third in some studies) of false positives can lead to unnecessary prostate biopsies that have risks such as bleeding and serious infections.

Many have expressed concern that the USPSTF’s new recommendations will affect governmental policy and fuel the insurance companies’ ability to deny payment in the future. So far there has been no indication that this will happen and hopefully these important decisions will still be left up to you. Current cancer screening methods should be made available to patients should they decide to have them done after speaking with their doctor.

The recent debate, outrage and speculation over cancer screening has highlighted the need for you to talk with your doctor and consider the possibility of those false positives and what the next steps will be if the screening tests come back positive. The question about what your level of comfort is in all of the uncertainty of screening is the most important question for you to answer in order to create the screening approach that’s best for you.

The controversies involved in the current screening techniques point out the need for more medical research in refining and developing better cancer screening methods that have fewer false positives and provide better outcomes for patients.

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