News about the risks or benefits of widespread cancer screening seem to arrive daily – 3D mammography for breast cancer, CT scans for lung cancer, PSA tests for prostate cancer and now pelvic exams for some women’s cancers. Missing in the headlines is a reflection of how cancer detection is evolving.
Today’s cancer experts say screening advice shouldn’t be one-size-fits-all. For most cancers, they advocate individual assessments based on each person’s history. This assessment may lead to more specialized screening – or to no screening at all.
An annual consultation with a primary physician, now standard in the wake of health care reform, should make patients aware of their individual risk. From there come more refined choices.
Breast cancer: Balancing risk against benefit
The U.S. Preventive Services Task Force recently recommended less frequent mammograms for women at lowest risk of the disease, but experts continue to debate the ideal age to begin screening, when to stop screening and who should be screened. Even top medical organizations remain at odds. The American Cancer Society maintains a recommendation that yearly mammograms should begin at 40, but the U.S. Preventive Services Task Force recommends women receive mammograms from ages 50 to 74, and then only every two years.
“It’s such a contentious issue – more about emotion than data,” said Joanne Mortimer, M.D., director of Women’s Cancers Program at City of Hope. “Risk assessment is really very critical. We harp on individualized health care, and that means understanding each woman’s risk. At low risk, don’t expose them to radiation unnecessarily. Women at very high risk – they may need mammograms and they may also need an MRI.”
High-risk patients typically receive screenings every six months, alternating between an MRI and mammogram. About 5 to 10 percent of breast cancer cases are considered hereditary, and the most common known cause of hereditary breast cancer is a mutation in the BRCA1 and BRCA2 genes. Those with the gene mutation may be at an 80 percent risk of developing breast cancer. These cancers tend to occur in younger women and more often affect both breasts than cancers in women who do not have the mutation.
Other women who may be at high risk include those who have been exposed to chest radiation or who have had a prior cancer. Even women who have tested negative for one of the known cancer mutations, but have a strong family history of breast cancer, might also be high risk.
Lung cancer: A question of cost
Obviously, widespread screening for many diseases – with the right guidelines and medical evidence to back it up – has the potential to save lives. The issue, however, becomes one of cost. Take, for example, lung cancer, which is the leading cause of cancer death in the U.S.
The U.S. Preventive Services Task Force recently developed guidelines to screen for lung cancer based on one of the most rigorous cancer screening studies ever performed, the National Lung Screening Trial. The guidelines recommend low-dose CT scans for current and former smokers ages 55 to 79 who smoked the equivalent of a pack a day for at least 30 years.
As many as 60 percent of lung cancer deaths could be prevented with screening, studies have found, and the new recommendations are very specific. Based on scientific evidence and individual risk for lung cancer, they say, widespread lung cancer screening has the potential to save lives.
“The bottom line is that lung cancer accounts for nearly 30 percent of all cancer deaths, largely because without screening, it isn’t discovered until it’s at an advanced stage,” said Dan Raz, M.D., co-director of the Lung Cancer and Thoracic Oncology Program, who recently testified before a Centers for Medicare and Medicaid Services (CMS) panel on the benefits of screening for lung cancer.
This spring, a panel made a nonbinding recommendation to CMS that Medicare should not cover screening for lung cancer – a move that stunned lung cancer experts nationwide. Later this year, CMS will take up the issue again to make a final decision.
Second thoughts about prostate cancer tests, colonoscopies and pelvic exams
Even many once-routine screenings are getting a second look.
Thinking has shifted in recent years away from routine PSA testing for prostate cancer, which most experts agree is a more useful tool for cancer monitoring than for cancer screening. And although colonoscopies are common, there’s some debate about whether fecal occult screening should become the norm.
The most recent one-size-fits-all screening to be recommended for elimination is routine pelvic exams for women. This exam – in which physicians use their hands to feel for the size and shape of the ovaries and uterus – has not been shown to be useful for reliably catching cancers. However, experts worry that women will skip their regular Pap smear test, which has been useful in lowering mortality rates from cervical cancer. The Pap smear test continues to be recommended.
“The further and further we get toward cost savings, the less we’re recommending any type of routine screening examinations,” said Robert Morgan, M.D., co-director of the Gynecological Oncology/Peritoneal Malignancy Program at City of Hope. "If we take routine testing out of the usual practices of women in society, then other very important practices, particularly screening Pap smears for cervical cancer, will tend to be neglected," Morgan told Medpage Today.
"Granted, if you got 50 patients who are asymptomatic, 49 of them may be OK, but one of them may have high blood pressure that you may need to find," Morgan told Breakthroughs. "The question becomes: Where do you draw the line?”
In fact, medical experts will be looking at many lines. But each cancer has a variety of lines, as does each person.
Ideally, cancer screening – when to screen, whom to screen and how to screen – should be dictated not by emotion, but by science, and not by cost alone, but by what will save the most lives.
Learn more about becoming a patient or getting a second opinion at City of Hope by visiting us online or by calling 800-826-HOPE (4673). Our staff will explain what previous medical records we'll need for your first appointment and help you determine, before you come in, whether or not your insurance will pay for the appointment.