Physician group compiles cancer screening recommendations, and recommends…less
Less may be more when it comes to cancer screening. “Study after study has consistently shown that patients and many physicians overestimate the benefits and are unaware of and/or downplay the potential harms of cancer screening,” said Dr. Wayne J. Riley, president of the American College of Physicians. Riley made his comments in May, following publication of the ACP’s advice for screening average-risk adults without symptoms for five common cancers, published in the Annals of Internal Medicine
“ACP wants smarter screening by informing people about the benefits and harms of screening and encouraging them to get screened at the right time, at the right interval, with the right test,” Riley was quoted as saying.
ACP reviewed clinical guidelines and evidence synthesis issued by the U.S. Preventive Services Task Force, the American Academy of Family Physicians, the American Cancer Society, the American Congress of Obstetrics and Gynecology, the American Gastroenterological Association, the American Urological Association, and ACP.
“We found much common agreement on high-value-care screening among different organizations,” said Dr. Tanveer Mir, chair of ACP’s Board of Regents and a member of ACP’s High Value Care Task Force, which developed the papers.
ACP’s High Value Care initiative is designed to help doctors and patients understand the benefits, harms, and costs of tests and treatment options for common clinical issues, so they can pursue care together that improves health, avoids harms, and eliminates wasteful practices, according to ACP. High-intensity screening strategies – screening broader populations, more frequently, and/or with more sensitive screening tests – are not necessarily high-value care, according to the organization.
“The largest harm that can result from overly intense screening is over-diagnosis and overtreatment,” Riley said. “The more sensitive the test we use or lower the threshold we establish for an abnormality, the more abnormalities we find – many of which will never lead to health problems. But because doctors cannot know which of these would or would not cause problems, we tend to treat them. Treatment for cell and tissue abnormalities that will likely not cause health problems cannot provide benefits.”
Screening average-risk adults ages 50 to 75 for colorectal cancer with high sensitivity fecal occult blood testing every year is an example of high-value care, according to ACP. On the other hand, screening women without a cervix for cervical cancer is an example of low-value care.
Meanwhile, prostate cancer, when detected with the prostate-specific antigen (PSA) test, never becomes clinically significant in a patient’s lifetime in a considerable proportion of men, according to the ACP. Screening using the PSA test in average-risk men under the age of 50 years or over the age of 69 years can open the door to more testing and treatment that might actually be harmful. If cancer is diagnosed, it will often be treated with surgery or radiation, which increases the risk for loss of sexual function and loss of control of urination compared to no surgery, according to the ACP. (This does not apply to those men considered to be in high-risk groups such as African American men and/or those with a strong family history of prostate cancer.)
Following are some points of “high-value-care advice” from the ACP, based on its research.
- Clinicians should discuss the benefits and harms of screening mammography with average-risk women aged 40 to 49 years and order biennial mammography screening if an informed woman requests it.
- Clinicians should encourage biennial mammography screening in average-risk women aged 50 to 74 years.
- Clinicians should not screen average-risk women younger than 40 years or aged 75 years or older for breast cancer or screen women of any age with a life expectancy less than 10 years.
- Clinicians should not screen average-risk women of any age for breast cancer with MRI or tomosynthesis.
- Clinicians should not screen average-risk women younger than 21 years for cervical cancer.
- Clinicians should start screening average-risk women for cervical cancer at age 21 years once every three years with cytology (Papanicolaou [Pap] tests without HPV tests).
- Clinicians should not screen average-risk women for cervical cancer with cytology more often than once every three years.
- Clinicians may use a combination of Pap and HPV testing once every five years in average-risk women aged 30 years or older who prefer screening less often than every three years.
- Clinicians should not perform HPV testing in average-risk women younger than 30 years.
- Clinicians should stop screening average-risk women older than 65 years for cervical cancer who have had three consecutive negative cytology results or two consecutive negative cytology plus HPV test results within 10 years, with the most recent test done within five years.
- Clinicians should not screen average-risk women of any age who have had a hysterectomy with removal of the cervix for cervical cancer.
- Clinicians should not perform cervical cancer screening with a bimanual pelvic examination.
- Clinicians should encourage colorectal cancer screening by one of four strategies: high-sensitivity FOBT or FIT (every year); sigmoidoscopy (every five years); combined high-sensitivity FOBT or FIT (every three years) plus sigmoidoscopy (every five years); or optical colonoscopy (every 10 years) in average-risk adults aged 50 to 75 years.
- Clinicians should not screen for colorectal cancer more frequently than recommended in the four strategies mentioned previously.
- Clinicians should not conduct interval screening with fecal testing or flexible sigmoidoscopy in adults having 10-year screening colonoscopy.
- Clinicians should not screen for colorectal cancer in average-risk adults younger than 50 years or older than 75 years or those with an estimated life expectancy of less than 10 years.
- Clinicians should not screen average-risk women for ovarian cancer.
- Clinicians should have a one-time discussion (more if the patient requests them) with average-risk men aged 50 to 69 years who inquire about PSA-based prostate cancer screening to inform them about the limited potential benefits and substantial harms of screening for prostate cancer using the PSA test.
- Clinicians should not screen for prostate cancer using the PSA test in average-risk men aged 50 to 69 years who have not had an informed discussion and do not express a clear preference for screening.
- Clinicians should not screen for prostate cancer using the PSA test in average-risk men younger than 50 years or older than 69 years or those with a life expectancy of less than 10 years.