I see that the kerfuffle over screening for cancer has erupted again to the point where it’s found its way out of the rarified air of specialty journals to general medical journals and hence into the mainstream press. This is something that seems to pop up every so often, much to the consternation of lay people and primary care doctors alike, often trumpeted with breathless headlines along the lines of “What if everything you knew about screening was wrong?
It isn’t, but some of it may be. The problem is the shaking out process. I’ll try to explain.
Over the last couple of weeks, articles have appeared in newspapers such as the New York Times and Chicago Tribune, radio networks like NPR, and magazines such as TIME Magazine pointing out that a “rethinking” of routine screening for breast and prostate cancer is under way. The articles bear titles such as A Rethink On Prostate and Breast Cancer Screening, Cancer Society, in Shift, Has Concerns on Screenings, Cancers Can Vanish Without Treatment, but How?, Seniors face conflicting advice on cancer tests: Benefit-risk questions lead some to call for age cutoffs, and Rethinking the benefits of breast and prostate cancer screening. These articles were inspired by an editorial published in JAMA last month by Laura Esserman, Yiwey Shieh, and Ian Thompson entitled, appropriately enough, Rethinking Screening for Breast Cancer and Prostate Cancer. The article was a review and analysis of recent studies about the benefits of screening for breast and prostate cancer in asymptomatic populations and concluded that the benefits of large scale screening programs for breast cancer and prostate cancer tend to be oversold and that they come at a higher price than is usually acknowledged.
It is easy to read the headlines and think that screening does not work. It does but we also need to recognize that just doing more screening does not necessarily help if we do not really understand all the facets underlying the disease being screened for.
It turns out that a significant minority of breast cancers resolve on their own. We really do not have a good way of knowing which ones have to be treated now and which would resolve without treatment. Some cancers might be very slow growing and present a very small chance of mortality. But, again, we can not really tell the difference, so all get treated the same.
As the blog post states:
So what’s the solution? Should we give up on screening?
I’ll answer the second question with an emphatic absolutely not. There is no doubt that screening can save lives; the problem is that we’re doing it “bigger” and “badder” and not necessarily better or smarter, using more or less a one-size-fits-all approach when a more tailored approach might actually be necessary. Also, we’re using 20th century technology, when 21st century technology might be able to find a way out of these conundrums. Here’s where I (mostly) agree with Esserman et al. We need to change how we screen for common cancers using the latest advances in biochemistry, molecular biology, and technology to differentiate which lesions are most likely to be cancer and which are not, which cancers are likely to progress to the point of threatening a patient’s life in their remaining lifespan and which ones are not.
We need to improve our screening approaches by having a better understanding of all the biology involved, including the specific biology that an individual possesses. We will get there but it may be a little confusing until then.