published Sunday, March 13th, 2011

Experts debate value of routine screenings

OVERDIAGNOSIS


by Emily Bregel
Dr. Lynn Swearingen uses a microscope to examine slides of tissues from a breast cancer patient at Parkridge Medical Center. 
Staff photo by John Rawlston/Chattanooga Times Free Press
Dr. Lynn Swearingen uses a microscope to examine slides of tissues from a breast cancer patient at Parkridge Medical Center. Staff photo by John Rawlston/Chattanooga Times Free Press

COVER STORY SIDEBAR—Breast, prostate screenings are under scrutiny

The questions fly in the face of a medical concept that seems indisputable: The earlier the diagnosis, the better.

We learn the value of screening tests in movies, when a doctor shakes his head and says, “If only we’d caught it sooner.” We read about in the newspaper, where articles lead with the survival stories of patients who say their lives were saved by a routine screening.

We see it in annual races and pink ribbons and T-shirts calling for more mammograms, hospitals and clinics offering free prostate cancer screenings and TV personalities undergoing on-air colonoscopies.

  • photo
    Dr. Lynn Swearingen uses this device to digitally capture images as she looks through a microscope to examine slides of tissues from a breast cancer patient at Parkridge Medical Center. Staff photo by John Rawlston/Chattanooga Times Free Press

But many doctors in Chattanooga and elsewhere are concerned about unquestioning acceptance of the value of routine screenings in healthy patient populations. Some fear that across-the-board screening can lead to unnecessary, costly and debilitating treatments for patents who never would have experienced any symptoms, let alone death, from their “disease.”

“Overdiagnosis is real,” said Dr. Wayne Scott, Chattanooga internal medicine specialist. And it’s fueled by the media, patient demand for tests and doctors’ fears about legal ramifications if they cut back on scans, doctors say.

“Parade [magazine] says, ‘Go get this [screening] done,’ so someone’s in my office to get it done,” Scott said. “Sometimes that’s a very good thing, but sometimes it’s not.”

But the issue of overdiagnosis versus thorough medical care is confusing, nuanced, political and emotional. It’s a question that’s hard to address adequately in a TV sound bite or a 10-minute patient visit, doctors and experts say.

And patients are sensitive to the idea of scaling back care, even based on evidence.

“In our culture, overtesting is equated with good care. You reduce [testing] and that’s equated with poor care,” said Dr. Patricia McLelland, a Chattanooga obstetrician-gynecologist.

Heightened scrutiny and updates of screening protocols for conditions such as breast, prostate and cervical cancer are challenging doctors, who sometimes struggle to square research-based recommendations with the everyday realities of clinical practice.

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    Dr. Lanett Varnell reads mammograms Thursdsay at the Mary Ellen Locher Breast Center. Dr. Varnell believes that mamograms are "very important to womens' well-being and long-term breast health, but other experts question the value of some screenings. Staff Photo by Angela Lewis/Chattanooga Times Free Press

“People get bogged down with population statistics,” said Dr. Amar Singh, chief of minimally invasive surgery in the urological oncology department at Erlanger. “Well, population statistics may not represent that individual case. You have to take that with a grain of salt and [an] open mind.”

More doctors are discussing with patients the value of getting tested if they don’t have symptoms, and of going forward with treatment if something is found, Singh said.

Two large-scale studies of prostate cancer screenings released in 2009 questioned whether they save lives. That led the American Cancer Society to push for greater patient education about screening, and for doctors and patients with normal risk levels to agree on individual screening plans. The U.S. Preventive Services Task Force already had said there’s not enough evidence about the benefits of routine screening in men younger than 75, and recommended against screening for those 75 and older.

“That’s a very tricky judgment decision that I think a lot of physicians are thinking a little more critically about,” Singh said. “It’s much easier to treat everybody. One thing I’m realizing [is] it takes me longer to talk people out of treatment than it does to talk them into treatment.”

LIMITS TO SCREENING

Routine screenings also have been touted as a way to reduce skyrocketing health care costs.

Health care reform has allocated $15 billion over 10 years to expand disease prevention and early detection infrastructure.

Those efforts might improve health outcomes but probably won’t save money, according to health policy experts and the Congressional Budget Office.

Less money is saved by early diagnosis and treatment than is spent screening people who never would have become ill, said Gil Welch, health policy expert at Dartmouth’s Institute for Health Policy and Clinical Practice.

CANCER IMPACT 2010

• New breast cancer diagnoses — 207,090 (female); 1,970 (male)

• Deaths from breast cancer — 39,840 (female); 390 (male)

• New prostate cancer diagnoses — 217,730

• Prostate cancer deaths — 32,050

Source: National Cancer Institute

Well-meaning advocacy groups for particular diseases also fuel desire for screenings, sometimes in spite of science-based recommendations, experts say.

And the groups aren’t immune from financial pressures.

“The American Cancer Society gets a lot of money because of breast cancer,” said Dr. Bruce Calonge, chairman of the U.S. Preventive Services Task Force. He also is president and CEO of The Colorado Trust, a foundation focused on improving health in Colorado.

“Susan G. Komen gets all of their money because of breast cancer. Because of advocacy, we have oversold the benefit of mammography,” Calonge said.

The U.S. Preventive Services Task Force, is a federally funded, independent panel of experts in evidence-based preventive medicine. Their advice forms the basis of clinical standards for many professional societies and health organizations and is used in medical schools teaching preventive care.

Since mammography became commonplace in the 1980s, death rates from breast cancer have declined steadily, according to the American Cancer Society.

Between 1990 and 2006, death rates decreased by 3.2 percent annually among women under 50, and by 2 percent annually among women 50 and older.

But researchers ask how much of that decline came from screening rather than greater awareness and improved treatments.

A study last year in the New England Journal of Medicine found that mammography accounted for one-third of the decline in breast cancer deaths among 40,000 Norwegian women, which was unexpectedly low.

And a 2009 study in the Journal of the American Medicine Association said the result of more than 20 years of screening for breast and prostate cancer is “troubling.”

Breast cancer

• The U.S. Preventive Services Task Force: Women with a normal risk level get their first mammogram at age 50 instead of the previous recommendation of 40. Those exams come every two years instead of every one or two years.

• The American Cancer Society: Still recommends annual mammograms starting at 40 for women with a normal cancer risk level.

Prostate cancer

• The American Urological Association: Men 40 and older with a life expectancy of at least 10 years should be offered a baseline PSA test and digital rectal exam for early detection and risk assessment. Doctors should discuss the benefits and risks of testing, before screening.

• The American Cancer Society: Men without a family history can wait until age 50 to have a conversation with their doctor about the risks and potential benefits of PSA screening and make a decision on an individual level.

• The U.S. Preventive Services Task Force: Says there is insufficient evidence about the benefits of routine screening in men younger than 75 and recommends against screening for those 75 and older.

Colon cancer

• The U.S. Preventive Services Task Force: For those with normal risk level, recommends regular screening from age 50 to 75, either annual high-sensitivity fecal occult blood testing, sigmoidoscopy every five years combined with fecal occult blood testing every three years, or colonoscopy every 10 years.

• American Cancer Society: Various options, including colonscopy every 10 years, sigmoidoscopy every five years or virtual colonoscopy every five years.

Although more early-stage cancers have been diagnosed, there has been no proportionate decline in later-stage cancers.

The results suggest more low-risk breast and prostate cancers are being detected, but not as many of the more aggressive cancers that become fatal.

“Overall cancer rates are higher, many more patients are being treated, and the absolute incidence of aggressive or later-stage disease has not been significantly decreased. Screening has had some effect, but it comes at significant cost, including overdiagnosis, overtreatment and complications of therapy,” the study said.

But cervical and colon cancer screenings have been accompanied by a significant decrease in late-stage invasive cancers, the study said.

Mammography guidelines were in the spotlight two years ago, when the U.S. Preventive Services Task Force scaled back its recommended frequency of screenings for women with a normal risk of breast cancer.

The group said women should begin getting mammograms at age 50 instead of 40, and get them every other year instead of every one or two years. The group did not recommend mammograms for women over 74 and said studies didn’t show evidence that breast self-examination saved lives.

The American Cancer Society has maintained that mammograms should start at 40.

About 85 percent of women diagnosed with breast cancer don’t have a family history, making earlier screenings important for everyone, said Lisa Bishop, executive director for the Southeast Tennessee American Cancer Society.

“We do have women being diagnosed in their 40s with breast cancer. There’s enough to justify keeping the guideline at age 40,” she said.

But others say it’s a very close call.

Mammograms aren’t useful in identifying whether a cancer will be helped by treatment, Calonge said. Some cancers grow so quickly and aggressively even early detection can’t make a difference, he said. Others grow so slowly they will never become a problem, so detection and follow-up treatment — in the form of chemotherapy, radiation or surgeries — has no benefit.

“Somewhere in between those two extremes [is] where early detection and early treatment actually affects the outcome,” Calonge said. “One of our problems is we can’t tell the difference.”

Research must focus on developing detection methods that distinguish between cancers that are deadly and those that aren’t, he said.

HARD TO AVOID

For doctors, reducing overdiagnosis is easier said than done.

Chattanooga oncologist Dr. BW. Ruffner said doctors are “sometimes cursed by our technology.”

The ability to find minuscule early-stage cancers or pre-cancerous cells leads turns up abnormalities that may have gone away on their own or never developed into something dangerous. Patients and doctors must wrestle with an emotional — and potentially litigious — dilemma of whether to treat or to watch and wait.

What they’re saying

“The thing that gets lost in all this shuffle is that ... [prostate cancer] does kill people and the question is, who does it kill? Who is at risk? And that’s the group we need to go after and treat them.” —Dr. Amar Singh, urologist, chief of minimally invasive surgery in Erlanger’s urological oncology department

“How many unnecessary biopsies should you do in order to find one cancer, and how many cancers do you have to find early to actually save a life? There’s no easy dividing line in there.” —Dr. B W. Ruffner, Chattanooga oncologist

“There is definitely a danger of overdiagnosis if you screen inappropriately. You can be decreasing their quality of life without increasing their [survival] rate and that’s what we don’t want to do.” —Dr. Wayne Scott, Chattanooga internal medicine specialist

“One of the fastest ways to recruit new patients is screening. Free screenings can assure Medicare revenue through follow-up biopsies.” —Gil Welch, Dartmouth researcher, author “Overdiagnosed”

“How many times have you heard in a movie or TV or with your own doctor, ‘If only we had caught it sooner’? That actually sets us up for this belief that sooner is always better, and that may not be true.” —Bruce Calonge, chairman of the U.S. Preventive Services Task Force

“In our culture, overtesting is equated with good care. You reduce [testing] and that’s equated with poor care.” —Dr. Patricia McLelland, Chattanooga obstetrician-gynecologist

“How many unnecessary biopsies should you do in order to find one cancer, and how many cancers do you have to find early to actually save a life? There’s no easy dividing line in there,” Ruffner said.

The American College of Obstetrics and Gynecology now recommends women have their first Pap smears to detect cervical cancer at 21, rather than three years after they begin sexual activity. The change aims to cut down on invasive and sometimes harmful treatments for teens with abnormal results, who may have a human Papillomavirus infection that will resolve untreated.

McLelland said many women have difficulty bearing children because of treatments they received as teens following an abnormal Pap smear.

The college also recommends women in their 20s get a Pap smear every two years, and women over 30 every three years, instead of annually.

But selling parents on delaying Pap smears isn’t always easy.

“I have had phone calls back from mothers saying, ‘Why aren’t you taking care of my child appropriately?’” she said. “You have to explain the chance of developing cervical cancer [for women under 21] is one in a million, and you’re only increasing your chance of unnecessary treatment.”

Dr. Laura Witherspoon, a breast surgeon with University Surgical Associates in Chattanooga, said she’ll continue to recommend mammograms for women in their 40s.

“There’s always some problem between the interface of public health and everyday practice,” Witherspoon said. “The primary cause of death for women in that age group is breast cancer because they don’t have any other diseases yet. What am I supposed to do with that information? It’s hard to know how to implement not doing mammography.”

Fear of lawsuits plays a major role in decisions and leads to “defensive medicine,” local doctors said.

Even if broad tort reform limited doctors’ liability, defensive medicine “is so ingrained into our practice behaviors I think it would take a whole generation to work it out,” Witherspoon said.

about Emily Bregel...

Health care reporter Emily Bregel has worked at the Chattanooga Times Free Press since July 2006. She previously covered banking and wrote for the Life section. Emily, a native of Baltimore, Md., earned a bachelor’s degree in American Studies from Columbia University. She received a first-place award for feature writing from the East Tennessee Society of Professional Journalists’ Golden Press Card Contest for a 2009 article about a boy with a congenital heart defect. She ...

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