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Cancer Screening: Me Vs. the Big Picture

The United States Preventive Services Task Force (USPSTF) last week handed down the startling recommendation that men over 75 should not be routinely screened for prostate cancer, and that younger men should weigh their screening options with a physician. That news came shortly after the release of a new study suggesting that teaching women to perform breast self-exams is not worthwhile in the grand scheme of things.

We don't much like the sounds of that, do we?

How can it be bad to use these tools to look for cancers that might otherwise go undetected -- and untreated -- until it's too late? Don't we all know of a man who is still alive because he took a PSA (prostate-specific antigen) test that found his prostate cancer before it killed him, or a woman who felt a lump in her own breast and had it removed, perhaps just in the nick of time?

The tough answer is that, while we make judgments for ourselves about the value of these screening devices based on our own or our acquaintances' experiences, those whose job it is to decide what the medical community should endorse look at the bigger picture.

According to Michael LeFevre, a family physician practicing in Columbia, Missouri and a member of the USPSTF, when it comes to looking for asymptomatic disease of any kind, whether it's high blood pressure or breast cancer, the benefits of screening have to be weighed against the risks. Organizations such as the Task Force review the best available scientific evidence and ask whether screening does more harm than good.

With PSA screening and breast self-exams, that "harm" can include biopsies that ultimately are deemed to be unnecessary, psychological distress, and, in the case of slow-growing prostate cancers in older men who are likely to die of something else before their prostate cancer kills them, treatments that do more damage (including causing impotence) than the cancer itself.

Sometimes, as with high blood pressure, the value of finding and treating the disease is found to outweigh the potential harm (in this case, using medications that can cause unpleasant side effects to treat someone who might not be headed for a heart attack or stroke), LeFevre notes. While there's no way of knowing which people with high blood pressure will end up having heart attacks, science shows that, across the board, it's clearly worth identifying people with the condition and getting them treated.

With older men's prostate cancer and women's breast cancer, though, the link between screening for disease and positive outcomes isn't so clear. Hence the new USPSTF recommendation. The USPSTF hasn't revised its guideline regarding breast self-exam since the new study was published; as it stands, the Task Force says there's not enough evidence to recommend for or against women's learning or performing the technique.

I understand all that -- in theory.

But I intend to keep checking my own breasts. How about you?

By Jennifer LaRue Huget  |  August 11, 2008; 7:00 AM ET
Categories:  Cancer  
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Until someone comes up with a test for breast cancer that works on younger women, unlike mammography, breast self exam IS important for every woman to know. When I was 34 years old (with no family history of breast cancer), I had a lump in my left breast. The mammogram was clean (what a relief!), so I was told to monitor the lump and come back in three months if it was still there. By then, I found a lump in my right breast, too. A simple needle biopsy confirmed that I had a malignant tumor in each breast. No one at the time explained to me -- until I specifically asked -- that mammography has a significant failure rate with younger, denser breast tissue. I'm now 51, grateful every day that I felt those lumps and pursued biopsies, and I'm a big proponent of breast self exam.

Posted by: EDT | August 11, 2008 12:26 PM | Report abuse

Not mentioned in the article, but undoubtedly considered by the USPSTF in their deliberations, is the issue of dollars and cents. That is, the additional (and perhaps unnecessary) cost of the biopsies that turn out negative, and the cost of the various prostate cancer treatments for the older men who will likely die of something else first.

Posted by: DFL | August 11, 2008 5:27 PM | Report abuse

My insurance company Medicare Complete just refused to pay for a prostrate specific AG test and left me with a $97.00 bill. I do have an inlarged prostrate and take medication for it. My doctor thought this test would be prudent in my case. I think this crap about test not being necessary is just a way for the insurance companies to get out fo paying clams. The test came back negative so I plan to be around for a while to gripe about this hogwash.

Posted by: Old Coot | August 11, 2008 8:15 PM | Report abuse

The problem with these studies is it's not clear how one goes about calculating the relative worths of the costs and benefits. That is, for example with breast self-exams, what value do you assign to the "costs" of a bunch of unnecessary biopsies vs. the value you assign to the "benefit" of saving one woman's life?

I mean, really, how do you compare those? I have no idea, but obviously the task force must have some way.

Moreover, wouldn't each individual be likely to weigh the "costs" and "benefits" differently? i.e. assign different values to those costs and benefits based on their own personal feelings toward them?

For example, some women might decide that they'd rather have unnecessary biopsies if there was a 1% chance of cancer vs. other women who would require a 10% chance of cancer. How in the world a particular institute can decide this is beyond me.

Now, in the case of the PSA test for old men, it's a little clearer because the ultimate question is whether the cancer or something else will kill you first. In the case of the women with breast self-exams, we're talking, on average, much younger women who will, if not treated, die of the cancer. So, the question is: How does doing the breast self-exams hurt? I mean, if you don't do them and you have breast cancer, how will you know? Will you have to wait for your doctor to do the breast exam (is that really THAT different from you doing it)? What if you don't go to the doctor annually (as many people do not)? Should they do breast self-exams?

Really, this is all rather stupid. Just do the breast self-exams and screw these studies.

Posted by: Ryan | August 11, 2008 8:50 PM | Report abuse

A country is in a sad state when it has to start rationing health care when insurance companies and drug companies cause a major portion of the expense. Hospitals and doctor's clinics have more people working in the billing department then they have doctors. Insurance companies have people hired to persuade their clients that they do not need medical treatments. I had better health care fifty years ago than I have now and they call that progress? Give me a break.

Posted by: Old Coot | August 11, 2008 10:43 PM | Report abuse

Everyone who reads these studies seems to make the same mistake. They say, "well, it's common sense that this test will work, so I'll ignore the actual odds and go with my gut."

To answer Ryan, the costs of treatment are not being measured in dollars and cents. They are being asked as "will this procedure increase my life expectancy?" For prostate cancer, the numbers show that aggressive screening does not actually improve your life expectancy.

The explanation for this is that any advantage gained by early detection is outweighed by the negative aspects of diagnosis: overly aggressive treatment, medical errors, and the stress which is caused by worrying about your health.

There are a couple of important things to remember here. First, for any condition which affects a small percentage of the population (5%), even a highly accurate test (95% accuracy) will produce as many false positives as true ones. Since most conditions affect less than 5% of those screened, and since most tests are less than 95% accurate, the end result is that far more false positives than false negatives occur. For example, if 1% of the population has a condition, and the test is 90% accurate, you will have 10 false positives for every real one. So for every patient whose early detection has a positive impact on their treatment, 10 other patients are needlessly treated for a condition they don't actually have.

The other reality which is often glossed over is that five or ten-year survival statistics are a competely meaningless measurement of the effectiveness of early detection, because detecting a condition earlier skews the statistic all by itself. Suppose I am going to die of cancer on January 1 2014. If I find out this year that I have cancer, my five-year survival rate is 100%. If I find out next year, my five-year survival rate is zero. In both cases, however, I will die on the same day.

The bottom line is that these new studies actually mean something. Their clear implication is that being involved in the medical system is bad for you -- bad enough to outweigh any potential benefits caused by early detection.

I don't expect any of you to stop getting PSA tests or doing breast exams, but you should admit that your actions are motivated by sheer superstition. The odds are clear, but you choose to ignore them because you don't want to accept that there is no magic cure for either prostate or breast cancer. You can lie to yourself, but in the end, the facts don't lie.

So go ahead and ignore these studies. Personally I will continue to take the opposite approach -- avoid diagnostic testing at all costs unless you have either a predisposition or a symptom, take few or no medicines, and see a doctor only when you are sick. Not only will this improve your life expectancy, but it will save you time and money, while at the same time increasing your quality of life. How can you beat that?

Posted by: Steve | August 12, 2008 12:12 AM | Report abuse

Actually, Steve, YOU are misunderstanding something. Read the article again: The costs and benefits are not being weighed solely on the basis of whether the treatments will increase your life expectancy. In fact, it says quite clearly: "With PSA screening and breast self-exams, that "harm" can include biopsies that ultimately are deemed to be unnecessary, psychological distress, and, in the case of slow-growing prostate cancers in older men who are likely to die of something else before their prostate cancer kills them, treatments that do more damage (including causing impotence) than the cancer itself."

So, no, these studies do NOT just look at life expectancy. And, so, my post still stands: How are they assigning values to, say, unnecessary biopsies? How does put a value on that vs. extended life?

Also, there ARE benefits of SOME diagnostic screenings. In fact, it is only through diagnostic screenings that breast cancer death rates have plunged so dramatically over the past 30 years. If people waited until they felt "sick", that would mean that the cancer had spread beyond their breasts (i.e. metastasized). In that case, it is very difficult to treat breast cancer and the death rates would be much higher. In contrast, diagnostic screenings (whether self-exams, doctor exams, or mammograms) have done wonders.

Posted by: Ryan | August 12, 2008 10:09 AM | Report abuse

Judged by articles I've read on the study, it seems guilty of the well-known fallacy of applying traits of a group en masse to individuals within the group.

It's much like saying that because most criminal defendants are actually guilty of the charges aainst them that "you" are also guilty of the charges against you if you're a defendant in a criminal trial not yet held.

Posted by: Bill | August 14, 2008 7:50 AM | Report abuse

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