“We are in the midst of an epidemic of diagnosis. Conventional wisdom tells us that this is good. Finding problems early saves lives, because we have the opportunity to fix small problems before they become big ones. What’s more, we believe that there are no downsides to looking for things to be wrong. But the truth is that early diagnosis is a double-edged sword. While it has the potential to help some, it always has a hidden danger – overdiagnosis – the detection of abnormalities that are not destined to ever bother us.”
Overdiagnosed: Making People Sick in the Pursuit of Health by H. Gilbert Welch, Lisa Schwaretzl, Steve Woloshin, published by Random House, 2011
We are getting mixed messages about whether or not screening for cancer and other diseases is a good thing or a bad thing. We read in the media that early, aggressive treatment is always best, yet some have begun to question that mantra. The belief that cancer screening, for example, will save your life has come under attack. Research now confirms that some cancerous tumors would, in fact, never cause harm because they are too slow-growing to ever threaten your life. Others are so aggressive that finding them early does not make much difference. Then there are the situations where early detection can make all the difference, actually stopping diseases before they start, e.g. testing blood sugar for diabetes, checking blood pressure, cholesterol and EKG for hypertension and other cardiac issues.
Dr Welch issues a reasonable call for change that would save patients pain, worry and money when he contends that “overdiagnosis is a big problem with modern medicine that leads millions of people to become patients unnecessarily while adding huge costs to an already overburdened system.”
So what is an intelligent empowered patient supposed to do when, for example, there are qualified medical providers who clamor for eliminating screening for prostate cancer and postponing mammograms, while other qualified providers are not only encouraging these screenings but insisting on them for their patients?
We know that many of the screening tests have risks, including false positives that lead to invasive biopsies and in some cases irreversible side effects. On the other hand if we look at mammography we also understand that although mammograms don’t prevent breast cancer they can save lives by finding tumors as early as possible. Overall mammograms pick up 80-90% of cancers and have shown to lower the risk of dying from breast cancer by 35% in women over the age of 50. In women between ages 40 and 50 the risk reduction appears to be somewhat less. Some groups including the National Cancer Institutes, the American Cancer Society and the American College of Radiology currently recommend annual mammograms for all women over the age of 40. Others suggest that screening for breast cancer does not need to begin for the general female populace until age 50, with obvious exceptions such as women with a family history of breast cancer.
Creating even more confusion are the results of two long-awaited studies – one conducted in the United states and the other in Europe. These studies were supposed to settle the debate over the value of PSA (prostate cancer) testing. These trials, published in the New England Journal of Medicine, March 2009, appear to reach opposite conclusions. The Prostate Lung Colorectal and Ovarian (PLCO) Cancer Screening Trial reported no survival benefit with PSA screening and digital rectal examination. The European Randomized Study of Screening for Prostate Cancer (ERSPC), however, found a 20% reduction in prostate cancer deaths. The ERSPC study estimated that for every life saved, 48 men are treated and 1,068 men are screened.
Is it therefore left to the patient to figure out whether to undergo screening or not? This is one of the best examples of why being an empowered patient is so important. The patient must weight the benefits and risks, talk to your physicians and ask the following questions:
1. Which test do you recommend for me and why?
2. How much do the tests cost
3. Will my health insurance help pay for these screening tests?
4. How soon after the tests will I learn the results?
5. If the results show a problem, how will we learn if I have cancer?
6. What are my choices once a diagnosis is confirmed?
Patients also need to be sure that their physicians follow a sensible protocol before rusiing into screening tests, including the following:
1.Physical exam and history. This exam checks the body for general health as well as signs of disease such as lumps or anything else that seems unusual.
2. Laboratory tests. A first step following the physican exam should be the least invasive screenings including blood and urine
3. Imaging procedures including mammography might be the next step because they are also less invasive
4. Genetic tests executed by drawing blood, that look for certain gene mutations (changes) that are linked to some types of cancer are another non-invasive screening option, although they are quite costly
5. Finally if there is enough evidence, a biopsy might be warranted.
It is up to each patient to drive the screening process, communicate with your physician at every step and weigh all the alternatives before agreeing to tests that may not, in the long run, change your outcome. Below are websites that have cancer support advice and tool kits.