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Cancer Screening Policy Shift
Old 10-21-2009, 06:20 AM   #1
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Cancer Screening Policy Shift

In Shift, Cancer Society Has Concerns on Screenings

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The cancer society’s decision to reconsider its message about the risks as well as potential benefits of screening was spurred in part by an analysis published Wednesday in The Journal of the American Medical Association, Dr. Brawley said.

In it, researchers report a 40 percent increase in breast cancer diagnoses and a near doubling of early stage cancers, but just a 10 percent decline in cancers that have spread beyond the breast to the lymph nodes or elsewhere in the body. With prostate cancer, the situation is similar, the researchers report.

If breast and prostate cancer screening really fulfilled their promise, the researchers note, cancers that once were found late, when they were often incurable, would now be found early, when they could be cured. A large increase in early cancers would be balanced by a commensurate decline in late-stage cancers. That is what happened with screening for colon and cervical cancers. But not with breast and prostate cancer.
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But some, like Colin Begg, a biostatistician at Memorial Sloan-Kettering Cancer Center in New York, worry that the increased discussion of screening’s risks is going to confuse the public and make people turn away from screening, mammography in particular.

“I am concerned that the complex view of a changing landscape will be distilled by the public into yet another ‘screening does not work’ headline,” Dr. Begg said. “The fact that population screening is no panacea does not mean that it is useless,” he added.
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Old 10-21-2009, 07:38 AM   #2
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The screening value of many conventional tests has long been in question. Generally, the more a strategy is aimed at higher risk individuals, the more beneficial and cost-effective it is; the more likely a + result truly represents the disease. Screenable diseases often have a prevalence of under 5% in the tested population. Examples of questionable strategies for a general population include colonoscopy after age 70, and even before; PSA testing; mammography. This does not mean that they are useless, only that the benefits are statistically so marginal that no net gain has yet been definitively detected (patients at higher risk are a different story).

A big issue is public perception. If a patient gets a PSA which is high, then gets a prostatectomy which has a tiny focus of cancer he will often be absolutely sure that the test saved his life. In fact, while that is one possibility, it is comparably likely that a) the disease never would have progressed, b) he might has had a serious of fatal complication of a surgery that may not have been necessary, c) at surgery the disease will be more advanced than thought and not curable, etc.

Typically, well-meaning advocacy groups lean toward aggressive screening more than the best science suggests for a lot of reasons.

While it is important not to get cynical about this, it is also not surprising that screening strategies sometimes fail.

My personal choice (YMMV) is to get PSA every 2 or 3 years, colonoscopy every 10 years but maybe call it quits at age 70; 5-years lipid checks. Things will change as technology evolves.
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Old 10-21-2009, 11:44 AM   #3
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Originally Posted by Rich_in_Tampa View Post

My personal choice (YMMV) is to get PSA every 2 or 3 years, colonoscopy every 10 years but maybe call it quits at age 70; 5-years lipid checks. Things will change as technology evolves.
Why call it quits at 70? Does colon cancer take so long to progress that there isn't much point in catching it early at that age? Or surgery is too risky by the seventies? Or?

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Old 10-21-2009, 11:45 AM   #4
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Seems strange the cancer society would discourage early detection. Could this be pressure from the gov't to reduce health care costs? I plan to get the standard testing as originally recommended.
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Old 10-21-2009, 01:10 PM   #5
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Seems strange the cancer society would discourage early detection. Could this be pressure from the gov't to reduce health care costs? I plan to get the standard testing as originally recommended.
Because for breast cancer and prostate cancer, screening doesn't work - overall people don't live longer if they are screened. And medical procedures (biopsies and treatment) are done unnecesarily because of positive tests* with unnecessary risks to the person and unnecessarily costs to the person (or to everyone if insurance or the government is paying).

*both false positives and positives caused by cancer that isn't a threat
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Old 10-21-2009, 01:13 PM   #6
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From DrMcDougall.com - concerning prostate cancer:

"Because of the common belief in early detection with PSA, prostate cancer has increased at least 10-fold in the past 2 decades. Honest doctors will tell patients that testing does more harm than good – because over 90% of men diagnosed with this disease will never die from it and would be better off not knowing about it. And those few who have a fatal form of this disease are far beyond the reach of current therapies at the time of diagnosis – so they are not helped either. Besides, the treatments are barbaric leaving men impotent and incontinent. "
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Old 10-21-2009, 01:22 PM   #7
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Why call it quits at 70? Does colon cancer take so long to progress that there isn't much point in catching it early at that age? Or surgery is too risky by the seventies? Or?
Most colon cancers take 5-10 years to go from small polyp to large polyp and then to cancer, and even in this case that occurs to a small fraction of patients.

So at 70 (assuming no polyps at that time) you are unlikely to ever get colon cancer, and if you do you'll be of such an age that you are equally or more likely to die of other natural causes. Throw in the small inherent risk of colonoscopy and other procedures. Bottom line is that as a life-prolonging strategy, it seems to stop working around that age in a population at normal risk.

Now once in a while someone will emerge who benefitted from doing otherwise, but for every one of them there are those who had no cancer but perforated their colon from a colonoscopy, or died early of cancer treatment complications while they may have lived a good number of years more without treatment.

You can see how complicated and emotional the whole thing becomes.
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Old 10-21-2009, 01:25 PM   #8
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Originally Posted by MuirWannabe View Post
Seems strange the cancer society would discourage early detection. Could this be pressure from the gov't to reduce health care costs? I plan to get the standard testing as originally recommended.
Just being "serious" is not enough to make a condition screenable.

It needs to be:
  • common enough to matter to the general population's welfare [we don't screen for rare diseases like leprosy],
  • detectable early with minimal risk and cost [after all whole segments of the population will take the test most of whom do not have the disease],
  • better treated early (before symptoms) than late treatment (after symptoms) [why screen for a disease which just as well with delayed treatment as with early treatment], and
  • the available treatments need to be effective enough to make this all worthwhile [why screen for a disease which has no good treatment].
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Old 10-21-2009, 01:57 PM   #9
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In the UK, they only test women aged 25 - 49 every 3 years for cervical cancer (pap smears.) After that every 5 years until age 64, then no more.

Apparently, it doesn't make sense to do it every year (like in the U.S. I think) unless you are known high risk. Doesn't change the outcome for most folks.

From what I've read, it seems as long as something abnormal is caught within those 3 year periods, most problems are treatable and flat out untreatable cervical cancer cases are rare since it's a slow growth cancer and would likely be caught in a treatable stage.

NHS Cervical Screening Programme

The effectiveness of the programme can also be judged by coverage. This is the percentage of women in the target age group (25 to 64) who have been screened in the last five years. If overall coverage of 80 per cent can be achieved, the evidence suggests that a reduction in death rates of around 95 per cent is possible in the long term. In 2007/8 the coverage of eligible women was 78.6 per cent3.

If I wasn't married, I wouldn't know anything about this stuff at all.
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Old 10-21-2009, 02:33 PM   #10
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I don't understand knocking off at age 64. Is the idea that women of this age are less likely to be exposed to the HP viruses that may set this cancer in motion?

If so, I think it is flawed. At this age more women may be widowed, or otherwise without a longtime partner and needing to go looking again.

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Old 10-21-2009, 06:12 PM   #11
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If you have organ confined cancer it is usually treatable and possibly cureable. If you do not detect the cancer before it becomes metastatic, it is much harder to treat , much less cure. If you do not screen for the common cancers, more cancers will be metestatic before they are caught. Anyone who tells you differently is either uneducated or blowing smoke up your @--....IMO
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Old 10-21-2009, 10:31 PM   #12
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I confess I'm no expert on cancer and quite happy of that fact for now. But what I do know is that the huge % of people die from either cancer or heart disease. Doing the screenings and tests to try and detect or stay out in front of these two areas seems wise to me. That just seems like common sense. I'm not talking about screening for leprosy. We're talking cancer.
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Old 10-21-2009, 10:42 PM   #13
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Quote:
Originally Posted by Rich_in_Tampa View Post
Most colon cancers take 5-10 years to go from small polyp to large polyp and then to cancer, and even in this case that occurs to a small fraction of patients.

...

Now once in a while someone will emerge who benefitted from doing otherwise, but for every one of them there are those who had no cancer but perforated their colon from a colonoscopy, or died early of cancer treatment complications while they may have lived a good number of years more without treatment.

You can see how complicated and emotional the whole thing becomes.
Thanks Rich - this aligned with my limited knowledge and my "gut feel" for the subject.


It's further complicated by a general public that really does not understand statistics very well. Couple that with some celebrity that was saved (or could have been saved) by early detection, and people extrapolate out the benefit without considering the risks.

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Old 10-21-2009, 11:02 PM   #14
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Originally Posted by MuirWannabe View Post
I confess I'm no expert on cancer and quite happy of that fact for now. But what I do know is that the huge % of people die from either cancer or heart disease. Doing the screenings and tests to try and detect or stay out in front of these two areas seems wise to me. That just seems like common sense. I'm not talking about screening for leprosy. We're talking cancer.
But you have to apply it to the entire population. Sure, high % of people die from cancer and heart disease in total. But a far fewer % die at age 50, at age 51, at age 52, etc.. Just to illustrate with some made up numbers, lets say that to catch that early enough to make a big difference in outcomes you need to screen every year. You are not just screening the people who were going to die from it (because you don't know that w/o the screening), you have to screen *everyone*, every year.

Let's say the risk increases at age 50, and average lifespan is 86. That means everyone would be screened an average of 36 times in their lives. There are risks (and costs) to that. People die from different kinds of cancer, and they require different screenings. And as Rich pointed out, it isn't so cut and dried that the early detection and treatment will result in an improved outcome. I know of a relative (not cancer related) where they would have been far better off w/o the early detection and treatment - the operation left them a mess, they never recovered and led a miserable life for the next few years and it was heartbreaking for their immediate family especially. Yet, they went into the hospital for this preventive surgery in good shape, and if untreated, they may have died suddenly (an embolism), maybe many, many years past when they did. Or maybe have died from something unrelated, and would have had those years to enjoy.

It has led me to be a bit more skeptical of preventive medicine - it certainly has its place, but there are risks to consider. Nords has made parallel comments regarding all the preventive maintenance they did on submarines- they often broke a perfectly fine piece of equipment just taking it out to inspect it. We are just fancy machines.

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Old 10-21-2009, 11:19 PM   #15
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I am 68 had a colonoscopy two years ago with one small benign polyp found. The risks of any procedure balanced against the possibility of finding a cancer: don't need another colonoscopy unless symptoms develop that indicate a potential problem.

My mother had breast cancer in her late 70s. Surgery disclosed it was encapsulated but the decision was made to remove the breast because she could not survive another surgery if in fact it had migrated. Roll of the dice here, she had Parkinson's and lived about another 12 years.

A cousin of mine thought is wise to have heart surgery at the age of 80, a quality of life decision. He died of a hospital acquired infection shortly after.

My father had surgery for a meningioma in his late 70s. The physicians said it was necessary because he would be paralyzed. He had mixed feelings about the surgery but went ahead. The surgery itself caused significant damage to his thinking, he had maybe 6 months of quality living after... and a couple years of enormous sadness. I think he would have been happier paralyzed.

It is my observation that surgeons operate because that is what they know. The patent's general practitioner needs to keep the focus on quality of life.
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Old 10-22-2009, 06:32 AM   #16
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Well, ain't that the way it goes nowadays -- News is like colorado weather, just wait a few minutes and it will change.

American Cancer Society Stands By Cancer Screening Guidelines - US News and World Report

Quote:
The American Cancer Society says it is not currently rethinking its stance on cancer screening, as was widely reported Wednesday.

"We are not redoing or rethinking our guidelines at this time, nor are we going to restate our guidelines to emphasize the inadequacies of screening," said Dr. Len Lichtenfeld, deputy chief medical officer of the American Cancer Society.
Earlier caution still holds -- read complete article for the "whole" story.
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Old 10-22-2009, 09:39 AM   #17
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This thread reminds of a This American Life episode I was listening to on my way home from work yesterday:

This American Life

What I got out of it: Doctor's are better off ordering tests to cover their a**.

After listening to the show, I don't blame them.
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Old 10-22-2009, 10:47 AM   #18
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If you have organ confined cancer it is usually treatable and possibly cureable. If you do not detect the cancer before it becomes metastatic, it is much harder to treat , much less cure. If you do not screen for the common cancers, more cancers will be metestatic before they are caught. Anyone who tells you differently is either uneducated or blowing smoke up your @--....IMO
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I confess I'm no expert on cancer and quite happy of that fact for now. But what I do know is that the huge % of people die from either cancer or heart disease. Doing the screenings and tests to try and detect or stay out in front of these two areas seems wise to me. That just seems like common sense. I'm not talking about screening for leprosy. We're talking cancer.
But it still makes sense to have appropriate recommendations for when to screen, based on the various factors Rich mentioned. As evidence is gathered those recommendations might change. After all, people don't get colonoscopies every year from the time they are 30. Instead it is 10 years starting at age 50 if no problems are revealed. This is because of the way colon cancer tends to work. And some cancers will be missed on this schedule. It is a balancing of risks, costs and benefits.
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Old 10-22-2009, 11:44 AM   #19
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But it still makes sense to have appropriate recommendations for when to screen, based on the various factors Rich mentioned. As evidence is gathered those recommendations might change. After all, people don't get colonoscopies every year from the time they are 30. Instead it is 10 years starting at age 50 if no problems are revealed. This is because of the way colon cancer tends to work. And some cancers will be missed on this schedule. It is a balancing of risks, costs and benefits.
Yes, certainly. That only makes sense. My original comment was only that the timing for these recommendation changes seemed very suspect given the gov't focus on health care costs. Probably coincidental. I'm all for reducing waste in the process. Would never consider annual colonoscopies (they are not that much fun ). But that has never been the recommendation for screening anyway. But the idea of avoiding any screening seems unwise. What you do with any informaiton found is then your decision but you at leas thave the information.
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Old 10-22-2009, 11:47 AM   #20
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OK, it goes something like this. These assumptions are consistent with a very good test, better than most (apologies to those who don't care to do the numbers):

  • Prevalence of the disease being screened for: 5%
  • Test sensitivity (percent of those with disease picked up by the test): 95% (it misses 5%)
  • Probabililty a positive test is "false" (no disease): 5% (5% of "positives" are false)
  • ------------------------
  • 1000 apparently healthy patients screened
  • 50 have the disease
  • 950 do not have the disease
Test result is abnormal (positive):
  • Picks up 95% of those with disease (95% of 50) = 47.5 true positives
  • Picks up 5% of those without disease (5% of 950)= 45 false positives
  • Of 92.5 patient with positive results, 45/92.5 or 49% are false positives = wrong.
Nearly half of all positive results are wrong, yet these patients end up undergoing additional studies, some of whichi are higher risk, expensive, etc.



Test result is normal (negative):
  • Of the 950 patients without disease, 95% will have an normal result: 902 true negatives
  • Of the 50 patients with disease, 5% will have a normal result: 2.5 false negatives.
  • Of 904.5 patients with normal results, almost all will be true negatives
Bottom line: in screening (low prevalence) situations, almost all negative (normal) results are right but many (50% and more) abnormal results are wrong (false positives). So what? Well false positives lead to further tests and cost, increased risk of additional incidental findings (usually of no importance but still requirng more tests), and the risk of 2nd line tests of an invasive nature.


I am not arguing for or against screening, only that there is a price to be paid and sometimes the risks exceed the benefits.
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