Cancer Screening: Life-savers Or Expensive Luxury?
Cancer screening techniques for breast and cervical cancer have come under scrutiny as health care expenditures soar.
According to the American College of Obstetricians and Gynecologists, cervical cancer rates have fallen more than 50% in the past 30 years due to the widespread use of the Pap test. The life-saving benefits of mammograms are less clear. A 2003 study gave the following figures: two out of 1,000 women in their 40's, four out of 1,000 in their 50's, and six out of 1,000 in their 60's are saved.
Despite the fact that the technology is far from perfect, worldwide mammogram screening remains the gold standard. Current medical guidelines in the US recommend mammograms to be performed annually starting at age 40. In other countries, screening usually starts at age 50.
After extensive research the US Preventive Services Task Force (USPSTF) issued new guidelines in November 2009 recommending that the starting age for mammograms be raised to age 50, recommended biennial screening mammography for women between the ages of 50 and 74 years and concluded that the current evidence is insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older.
These recommendations created quite a furor and started a heated debate between the 'Screen Less' and 'Screen Same' crowd. Most of the resistance has come from the organizations dedicated to improving the survival rate of breast cancer.
'Screen Less' is based on the following:
(1) Overusage. Like the PSA, mammogram screening leads to over diagnosis and overtreatment. Experts say that " many cases of breast mass detected by a mammogram are benign or not aggressive and just disappear with time or go into spontaneous remission. This raises the possibility that the natural course of some screen-detected invasive breast cancers is to spontaneously regress." Detection by mammograms, therefore, often leads to false alarms and unnecessary confirmatory tests, including invasive biopsy.
2) Too many false positives. One of the shortcomings of mammograms is the high rate of false positives which lead to false alarms and the unnecessary burden of worry and fear and also, ultimately results in many unnecessary procedures including invasive biopsies.
(3) Screening starting at 40 is too early. Comparison of breast cancer mortality rates found no significant differences between the US and other developed countries (UK and most of Europe) which screen starting at age 50.
(4) Radiation exposure. Women undergoing mammograms are exposed to low levels of radiation that may present some health risks. A study by Dutch researchers showed that in women who are at high risk for breast cancer, those who have BRCA1/2 mutation or a strong family history of breast cancer, actually increase their risk with mammogram exposures! This is especially true in young women exposed before age 20. The authors concluded: "Screening is very important. However, for young, high-risk women, a careful approach is advised when considering mammography for screening."
(5) Cost. Unnecessary mammograms are a huge financial burden. In 2005, the average cost of a mammogram in the US was 125US$. Most private insurance cover mammograms but women without coverage are most likely to take a pass.
Some advocacy groups believe money spent on unnecessary mammograms can be used better in providing quality health care for everybody, not only those who can afford it. In fact, the National Breast Cancer Coalition (NBCC) "has long questioned the limitations of mammography screening. For years it has been clear that mammography is not the answer to the breast cancer epidemic. At best, mammography screening may offer only very small benefits to certain age groups of women. There are public health interventions that could save more lives and use fewer health care resources than mammography screening programs".
On the other hand, the 'Screen Same' crowd base their contentions on the following:
(1) Breast cancer can hit before age 40. There are many cases of women without family history of breast cancer that were diagnosed with the disease at a very young age. For these women, screening and early diagnosis probably saved their lives.
(2) Insurance coverage. Although the recommendations are not legally binding, insurance companies may use the task force's findings to deny coverage of mammograms before age 50. US Health Secretary Kathleen Sebelius was quick to reassure that this wouldn't happen when she told MSNBC: The task force does "not set federal policy and they don't determine what services are covered by the federal government...Indeed, I would be very surprised if any private insurance company changed its mammography coverage decisions as a result of this action."
(3) Save lives, not money. The cost issue is,of course, a touchy topic. Former head of the National Institutes for Health (NIH) Dr. Bernardine Healy told Fox News: "This will increase the number of women dying of breast cancer. Women in their 40s have a very aggressive kind of breast cancer. They tend to progress fast. And to not screen women in that age group is astounding to me, and it goes against the bulk of individuals who are actually caring for patients. You may save some money... but you're not going to save lives."
(4) Better be scared than sorry. There are women who rather take unnecessary fear that false positives on mammograms may bring, than miss the chance of an early diagnosis and early treatment. According to breast cancer survivor and US Representative Debbie Wasserman Schultz: "We have to make sure that we're not forgetting about the people...Making -- these recommendations say that we can trade one life to save the angst and anxiety in a -- a larger group of women, and that's totally inappropriate..."
The American Cancer Society's (ACS) position is to ignore the USPSTF guidelines, based on the statement ACD Chief Medical Officer Dr. Otis W. Brawley: "The American Cancer Society continues to recommend annual screening using mammography and clinical breast examination for all women beginning at age 40."
Less debated, but nevertheless equally important, are the new guidelines on cervical screening issued by the American College of Obstetricians and Gynecologists (ACOG)in November 2009. Previous guidelines recommended that screening should start 3 years after the first sexual intercourse. The new guidelines fix the starting age at 21 and reduce the frequency.
The new ACOG recommendations are as follows: women from ages 21 to 30 be screened every two years instead of annually, using either the standard Pap or liquid-based cytology, Women age 30 and older who have had three consecutive negative cervical cytology test results may be screened once every three years with either the Pap or liquid-based cytology, Women with certain risk factors may need more frequent screening, including those who have HIV, are immunosuppressed, were exposed to diethylstilbestrol (DES) in utero, and have been treated for cervical intraepithelial neoplasia or cervical cancer.
ACOG based their new guidelines on the following:
(1) Avoid unnecessary interventions. ACOG believes that increasing the screening age starting at age 21 is a conservative approach that will spare young women from unnecessary interventions.
(2) Cervical cancer uncommon in the young. ACOG further defends its position by pointing to the fact that despite the fact that HPV is quite common among teenagers, aggressive cervical cancer is rare.
(3) Adverse effects on reproductive potential. ACOG refers to studies which indicated that invasive procedures at an early age can have some adverse effects on future childbearing potential. However, former NIH head Dr. Bernardine Healy who is a great opponent of the USPSTF recommendations, supports the new guidelines: "We know when it starts. It's a sexually transmitted disease. It takes a while to turn into cancer. You don't just get that infection and suddenly get cancer. It usually takes about 10, sometimes 20 years, unless you're immunosuppressed."
(4) Cost. As in mammograms, unnecessary screening tests for cervical cancer are a burden. Thus, by raising the minimum age and reducing the frequency, health care costs can also be reduced. Dr. Alan G. Waxman continues to explain: " A review of the evidence to date shows that screening at less frequent intervals prevents cervical cancer just as well, has decreased costs, and avoids unnecessary interventions that could be harmful."
The new guidelines were not met with strong resistance mainly because the cervical cancer data is more convincing. According to ACS spokesperson Debbie Saslow "There's good data since the last guidelines in 2003 that show that screening teens or before age 21 is not having an impact on reducing cervical cancer."
Change is hard. The controversy over the new guidelines, especially breast cancer screening, is at best confusing and is not much help to patients. Obviously, scientists and advocacy groups cannot agree which way to go. In the meantime, follow the advice of the NBCC: "Women who have symptoms of breast cancer such as a lump, pain or nipple discharge should seek a diagnostic mammogram. The decision to undergo screening must be made on an individual level based on a woman's personal preferences, family history and risk factors."
Better yet, this may be an opportune time to consider replacing the controversial and imperfect 'gold standard' mammogram with a less invasive screening tool. There must be something out there!
by: Katt Mollar
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