The truth about prostate cancer screening

Earlier this month, the American Cancer Society revised its recommendation for men regarding prostate cancer screening based on the latest research. Specifically ACS wanted men to ask their doctors about the limitations of PSA blood testing and digital rectal exams and their inability to improve survival.

Based on the National Cancer Institute's Prostate, Lung, Colorectal, and Ovarian screening trial and the European Randomized Study of Screening for Prostate Cancer, there was no evidence that screening with PSA made a difference in decreasing death from prostate cancer after a follow-up of seven years. While the European study showed a slight decrease in mortality with screening, this did not occur until about after nine years of follow-up. In other words, if this testing is helpful perhaps it will take until a ten year follow-up, before a decrease in prostate cancer rate is seen. Time will tell as the PLCO screening trial is still ongoing.

For now the American Cancer Society (ACS) recommends that men who are average risk (no family history or are not African American) should have a discussion with their doctors at age 50 about the limitations of PSA and rectal exams to find prostate cancer. If patients are unable to make a decision, then ACS suggests that doctors to the following:

After this discussion, those men who want to be screened should be tested with the prostate specific antigen (PSA) blood test. The digital rectal exam (DRE) may also be done as a part of screening.

• If, after this discussion, a man is unable to decide if testing is right for him, the screening decision can be made by the health care provider, who should take into account the patient’s general health preferences and values.
• Men who choose to be tested who have a PSA of less than 2.5 ng/ml, may only need to be retested every 2 years.
• Screening should be done yearly for men whose PSA level is 2.5 ng/ml or higher.

What to make of all of this? Medical research is constantly evolving. The more scientists investigate and study what works and what doesn't then the more precise doctors can figure out what must be done to keep you healthy. Despite public service announcements, prostate cancer screening has always been more controversial than screenings for other cancers because it wasn't clear that early detection made a difference. Certainly the most recent findings do nothing to change that sentiment.

For ACS, an organization focused on improving Americans' awareness to screen for cancer, to essentially tell men not to get prostate cancer screening demonstrates how unconvincing the evidence is that testing allows men to live longer. Another important learning is that patients need to understand that we still have a long way to go until we, doctors, have the tools to make precise diagnoses on which individual has an aggressive form of prostate cancer that requires medical intervention before becoming deadly and which others cancers are too small or slow growing to make a difference in a man's life.

Based on the latest evidence it is possible that with screening you might be diagnosed with prostate cancer, receive treatment that may include surgery or radiation which can result in impotence or urinary incontinence, as you and your doctor believe you've done the right thing to keep your self well. It is equally likely, however, that all of the interventions, treatments, pain, and complications you subjected yourself to made absolutely no difference.

So before you get a panel of blood work for a physical, ask your doctor if prostate cancer screening is proven to save lives. If he says yes, then you might want to print this out and ask him to explain the PLCO findings because you don't want to do more if it makes no difference it allowing to you live longer and healthier.

Breast Cancer Screening with Mammograms at age 40? 50? Who is the USPSTF?

When the U.S. Preventive Services Task Force (USPSTF) updated their recommendations and were against routine mammography for women aged 40 to 49, it certainly got a lot of attention. These guidelines are far different than those advocated by the American Cancer Society (ACS) which recommends screening starting at age 40 with annual mammograms.

• Who is the USPSTF?
• What does their recommendations mean for women?
• Why is there conflicting recommendations?

Who is the USPSTF?

The U.S. Preventive Services Task Force (USPSTF) is an independent committee of primary care and preventive physicians that periodically reviews the latest medical research and recommends tests and screening methods that have scientifically been shown to make a difference. As a result, its recommendations are the most conservative of any national organization.

The USPSTF’s recommendations are considered the “gold standard” for determining which clinical services are preventive. They review and look at various screening tests and preventive medications to determine whether there’s proof these interventions work and that the benefits they provide outweigh the potential harm. USPSTF indicates how strongly it recommends a particular method with a letter grade designation (A, B, C, D, and I). An A recommendation means that USPSTF strongly recommends that doctors provide a particular service to eligible patients. A B rating is simply a recommendation. A C means the task force recommends against routinely providing the service, but leaves the decision to the discretion of the individual doctor and patient. A D rating means the group recommends against providing for a particular intervention. An I recommendation indicates that there is not enough evidence to determine whether to recommend for or against a particular procedure.

The USPSTF recommendations tend to be the most conservative of any national organization, because they look for interventions that have proven benefits backed by research. Therefore, promising new technologies and tests that are yet unproven (and at times remain unproven or shown to be no better than existing tests) will not be recommended. As a result, the USPSTF’s guidelines may lag behind those of other organizations. But because they set such a high standard before recommending a particular treatment, insurers should cover the tests and procedures rated A and B.

From the November 2009 update on breast cancer screening update, the USPSTF recommended:

• Against routine screening mammography in women aged 40 to 49 years. The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms. Grade: C recommendation.
  

• Recommended biennial screening mammography for women aged 50 to 74 years. Grade: B recommendation.
  

• Current evidence is insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older. Grade: I Statement.
  

• Against teaching breast self-examination (BSE). Grade: D recommendation.
  

• Current evidence is insufficient to assess the additional benefits and harms of clinical breast examination (CBE) beyond screening mammography in women 40 years or older. Grade: I Statement.
  

• Insufficient evidence to assess the additional benefits and harms of either digital mammography or magnetic resonance imaging (MRI) instead of film mammography as screening modalities for breast cancer. Grade: I Statement.

What does this mean for women?

First, that there is some evidence that screening between ages 40 to 49 for breast cancer among women with average risk may not be as beneficial as we previously thought. There has been evidence from other countries, like Canada, which have suggested that. However, it is highly unlikely that the American Cancer Society (ACS), being an advocacy group for cancer awareness will change their stance. They said as much with the following:

The USPSTF says that screening 1,339 women in their 50s to save one life makes screening worthwhile in that age group. Yet USPSTF also says screening 1,904 women ages 40 to 49 in order to save one life is not worthwhile. The American Cancer Society feels that in both cases, the lifesaving benefits of screening outweigh any potential harms. Surveys of women show that they are aware of these limitations, and also place high value on detecting breast cancer early.

The American Cancer Society neglects to mention the potential number of extra women harmed with the extra screening between age 40 to 49. An additional 565 women need to be screened above and beyond the 1,339 women to save one life. Within this additional group, many women will have abnormal mammograms and require breast biopsies only to discover that the results were normal. The mammogram was a false-positive.

The USPSTF found in a study in the Annals of Internal Medicine, funded by the National Cancer Institute, that screening every other year achieved over 80 percent of the benefit of screening annually while cutting the false-positive result by nearly half. While every other year screening from age 50 to 69 years resulted in about a median 16.5% (range, 15% to 23%) decrease in breast cancer deaths compared to no screening, starting mammogram at age 40 decrease the death rate further by 3 percent, but increased the costs as more false-positive cases occurred. This article helped influence their recent decision.

Realistically for women, since ACS will not change their recommendation, is that mammograms will still be a covered benefit for any woman who desires to have a mammogram as early as age 40 and can be repeated annually.

What does this mean for you? If you are worried about breast cancer, consider getting screened starting at age 40, however, the benefit of screening may not be as good as we first thought. Certainly if there is a family history of breast cancer, you should discuss with your doctor whether mammography is enough or whether a breast MRI is needed.

Why are there conflicting information?

This won't be the first time USPSTF will have different recommendations than groups like ACS or other professional medical associations. Reasonable doctors and researchers can look at the same data and have different results. It speaks to the problem of screening for cancers and the tools that we currently have. The amount of precision that we would like as patients and doctors in identifying which group of individuals truly need a screening intervention and who does not have yet to be discovered. USPSTF and ACS disagree a bit on colon cancer screening as well. For example, when it comes to colon cancer screening USPSTF gives a grade A recommendation and suggests that:

Using fecal occult blood testing, sigmoidoscopy, or colonoscopy in adults, beginning at age 50 years and continuing until age 75 years. The risks and benefits of these screening methods may vary.

Yet, ACS also recommends virtual colonoscopy or stool DNA testing as reasonable alternatives even though there is no proof they save lives.

Stay tuned. Medical science continues to evolve and recommendations continue to change. The the mean time, exercise regularly, don't smoke, eat five servings of fruits and vegetables daily, and you might extend your life by an additional 14 years!

Your most crucial and trusted relationship is between you and your doctor. Questions? Speak up and ask. Don't be scared. Be informed.

Breast Cancer Awareness Month - Truths and Myths You Must Know

Besides being known for Halloween, the first full month of fall, and also a day to recognize Christopher Columbus, October is also known as breast cancer awareness month.

It not only is a good time to remind women to get screened for breast cancer, but also an excellent opportunity to clarify many myths that continue to persist among many women I meet in the office as well as community outreach programs I lead.

The lifetime risk of a woman developing breast cancer is one in seven. One common misconception is that breast cancer occurs primarily in women with a family history. In fact, the vast majority of breast cancers occur in women with no family history. The other misconception is that many women feel as they get older that their risk of developing breast cancer decreases. Their risk of breast cancer actually increases.

With increased awareness, thanks in part to the pink ribbons, the annual Susan G. Komen Race for the Cure, the breast cancer research stamp, and breast cancer awareness month, you would expect that women would be well informed about breast cancer. You’d think women would get regular mammograms, perform breast self-exams, and have regular clinical exams performed by physicians. An October 2005 article in the New England Journal of Medicine found that in fact mammography was largely responsible for the improvement in breast cancer survival over the past twenty-five years.

Despite this, women are not getting mammograms as suggested. In 2002, only 62 percent of women forty and older reported having a mammogram within the previous year. The number decreased to less than 40 percent in women without insurance. Another study showed that only two-thirds of women forty and older in New Hampshire received mammograms annually or biannually even though 97 percent had health insurance and over half (61 percent) were college educated.

Screening for breast cancer begins by doing a self breast examination monthly. Learn how to perform a breast self exam (BSE) correctly at www.komen.org/bse. To be completely thorough, also get a mammogram if it is indicated for your age group. Often, mammograms detect breast cancer at a much earlier stage and well before a lump is large enough to be felt by yourself or a doctor. Mammograms can also detect growths too deep in the breast to be felt by anyone. However, performing a breast self-exam regularly is equally as important, since some breast cancers cannot be identified by mammography.

Women are recommended to get mammograms annually starting at age forty. Make sure that your mammogram is performed by an accredited facility and the results are interpreted by qualified radiologists. Refer to the FDA Center for Devices and Radiological Health at www.fda.gov/cdrh and look for the mammogram program.

If you feel a lump, or your breast just doesn’t feel right to you, see your doctor right away even if you had a normal mammogram recently. Sometimes growths can occur and you may need another mammogram or other additional tests like an ultrasound.

Newer digital mammograms are on the horizon. Preliminary results have shown that these mammograms may be more effective in detecting tumors in women with dense breasts, who are not menopausal, or are under fifty years of age. And for women who do not fit into these categories, digital mammography was found to be equally as effective as traditional film-based mammograms.

In 2007, the American Cancer Society recommended breast MRIs as another way of screening for breast cancer in women who were considered high risk for developing the disease. (A lifetime risk of 20 percent or higher is considered high risk.) Your doctor has a variety of tools that can predict this risk. One is available from the National Cancer Institute at www.cancer.gov/bcrisktool.

If you are considered high risk, ask your doctor whether a breast MRI is right for you and whether your hospital can perform the test. It may be a while before your local MRI facility will have the appropriate setup and radiologists trained to interpret the breast MRI correctly. The breast MRI is to be used with a mammogram and should not replace mammograms. Women at high risk for breast cancer should consider getting both a mammogram and a breast MRI at age thirty. Women with a risk of 15 to 20 percent should ask their doctor whether a breast MRI is a good idea.

Regardless of whether you use traditional film-based or digital mammograms, if a mammogram is indicated for your age group get it done.

For more additional helpful insider tips you must know to keep well, get the easy to read book – Stay Healthy, Live Longer, Spend Wisely – Making Intelligent Choices in America’s Healthcare System.