In the New York Times on October 30, 2011, there was a very enlightening article by Gina Kolata on screening for three types of cancer: prostate, cervical and breast. Traditionally, the thinking has been that cancer screening is always the best means to prevent a cancer diagnosis. However, in the last two years, the United States Preventive Services Task Force, which reviews screening guidelines and analyzes cancer cases, has reported some eye opening findings and recommendations, including:
1. Women in their forties do not automatically benefit from annual mammograms, and women who are between the ages of 50 and 74 can have mammograms every two years, rather than annually;
2. The P.S.A. screening test for prostate cancer does not save lives, and the treatment performed as a result of abnormal P.S.A. tests can have serious negative effects; and
3. Women should consider having PAP tests for cervical cancer once every three years rather than annually.
The new thinking appears to be grounded on various studies that have analyzed the efficacy of cancer screening. For example, with regard to PSA testing, there were two large studies conducted, one in the United States and one in Europe. The U.S. study concluded that annual PSA tests do not lower the risks of dying from prostate cancer at all. The European study determined that a very small percentage of men in a certain age group might benefit from PSA screening every two to seven years, rather than annually. The issue is that in 90% of cases, prostate cancer grows so slowly that when these cancers are found in the early stage, they will never be life threatening. Further, the problem with PSA results is that if they are abnormal, this can lead to unnecessary procedures such as biopsies, which can cause incontinence and impotence.
There is also a misconception about PSA tests, which many believe can reveal cancer. In fact, PSA tests simply measure inflammation, which can be caused by normal enlargement of the prostate with age, an infection, strenuous bicycle riding or horseback riding, or recent sexual relations. Notably, the American Cancer Society does not recommend PSA testing, nor does the United States government.
Regarding mammograms, the Preventive Services Task force found that although mammograms discover cancer in 138,000 females annually, between 120,00 and 134,000 of these women have cancers which are already malignant or, conversely, at such an early stage that they do not require treatment. Dr. Otis Brawley of the American Cancer Society notes: “We need to be more cautious in our advocacy of these screening tests…no longer is it just, can you find the cancer?…now it is, can you find the cancer, and does finding the cancer lead to decrease in the mortality rate?” Dr. Brawley also pointed out that many if not most cancers grow very slowly, or stop growing altogether, and some even regress and don’t need to be treated at all.
Naturally, urologists, radiologists, and oncologists heavily promote and are firmly behind the annual screening protocol, but without question, there is a financial interest there, with all the money that is earned on testing, particularly MRI’s, CAT Scans, and other radiological examinations. Further, many doctors fear personal injury lawsuits, which cannot be discounted if a particular cancer is not diagnosed in time, even if screening would not have made a difference. Additionally, in many cases, due to the fear of cancer, patients will want to take their chances on the possible risks of screening to prevent the possibility of being diagnosed with a malignancy.
There was an astonishing statistic published in the current issue of the New England Journal of Medicine. Two prostate cancer specialists, Dr. Allan S. Brett and Dr. Richard J. Albin, noted in a recent study that more than 5 million dollars must be spent to prevent one prostate cancer death! Dr. Brett and Dr. Albin concluded that the P.S.A. screening approach is not appropriate in determining health care priorities. Dr. Brawley also pointed to the fact that we are viewing cancer from the 1845 definition of the German physician Dr. Rudolf Virchow, who looked at tumors in autopsies and defined them as uncontrolled growths that spread and kill. Yet Dr. Virchow never examined non-lethal cancers or tumors that stop growing or grow particularly slowly, as in many cases of prostate cancer.
One conclusion that can be drawn from the above studies is that before accepting the necessity of undergoing various screening examinations for cancer, you should have an in depth conversation with your physician as to the risks and benefits of the particular procedure, as well as the likelihood that you are a candidate for that particular type of cancer.
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