Debates intensify on tests for two cancers
Some say screening leads to overtreatment
Even before the American Cancer Society recommended the PSA test in 1992 to identify prostate cancer, questions had arisen about the test's value.
Screening to detect breast cancer in women has provoked similar concerns.
Now, a new analysis and statements from the American Cancer Society have underscored the intense debate within the medical community over the benefits of pushing early detection for these two cancers.
Last week, the Journal of the American Medical Association called for rethinking routine screenings for breast and prostate cancer.
Two decades of screening for the most-diagnosed cancers in women and men has not resulted in a decline in deaths, but has led to the unnecessary treatment of many patients. That drives up costs and risks complications, said experts from the University of California at San Francisco and the University of Texas Health Science Center at San Antonio.
"Screening does provide some benefit, but the problem is that the benefit is not nearly as much as we hoped and comes at the cost of overdiagnosis and overtreatment," wrote Dr. Laura Esserman, director of California's Carol Franc Buck Breast Care Center.
The experts called for research into finding new tests to distinguish dangerous cancers from harmless ones that will not cause a problem within a patient's lifetime.
The controversy has special resonance in Buffalo.
The PSA test was developed at Roswell Park Cancer Institute, where it remains a source of great pride. But Roswell Park also has drawn criticism for the way it presents information about the PSA test in its "Prostate Club for Men" marketing campaign.
A related story last week in the New York Times reported that the American Cancer Society, influenced by years of research, was preparing to change the message on its Web site to emphasize the shortcomings and risks of screening.
"I'm admitting that American medicine has overpromised when it comes to screening. The advantages to screening have been exaggerated," Dr. Otis Brawley, the society's chief medical officer, told the newspaper.
The story prompted the American Cancer Society to announce that its position on screening had not really changed and that it has no plan to alter its recommendations because, officials said, it already acknowledges the limitations of mammography and the PSA test.
"The process of screening is dynamic. Guidelines change as the science changes. We know we don't have the perfect screening test yet. But people still benefit greatly from the tests we have," said Dr. Victor Vogel, the society's national vice president for research.
Vogel said patients need to understand differences in the science of breast and prostate screening.
Clear understanding
Dr. Len Lichtenfeld, the society's deputy chief medical officer, took up the same issue in his blog, writing that mammography misses some lesions and detects others that otherwise would not cause harm to a patient. But the American Cancer Society believes that the evidence shows mammography and newer methods of treating breast cancer have reduced deaths, he said.
For prostate cancer, the American Cancer Society does not support routine screening but does recommend that men have a clear understanding of the possible benefits and risks from screening before they get a PSA test.
An advocacy group for men with prostate cancer criticized Brawley's comments, saying the PSA test has saved lives.
"Until a better diagnostic test is introduced, the PSA test is still the only short-term solution for early diagnosis and prompt treatment," said Linwood Norman, spokesman for ZERO: The Project to End Prostate Cancer, located in Washington, D.C.
The drawbacks and different opinions over screening have been well-documented.
This summer, for instance, the British Medical Journal published a study of cancer trends in five countries that concluded that one in three breast cancer patients identified in public screening programs may be treated unnecessarily for cancers that will do no harm.
Overshooting goal
Breast cancer screening should lead to a decline in advanced cancer cases in older women by detecting their tumors at an earlier stage. Instead, screening programs ended up identifying thousands more cases than in the past, which led to the unnecessary treatment of cancers that would never have become life-threatening, the researchers reported.
Similarly, an American study of 76,600 men released this summer found no difference in prostate cancer deaths between men who got a PSA test and those who didn't.
A similar study of 162,000 European men found that screening reduced cancer deaths by 20 percent, but a large number of men received unneeded treatment, such as surgery or radiation. On average, 1,408 men needed to be screened and 48 needed to be treated to prevent one prostate cancer death, according to the researchers.
"What we're seeing is the unintelligent use of the PSA test. We need to be screening everyone at risk of death and not everyone," said Dr. James Mohler, chairman of urology at Roswell Park and chairman of the National Comprehensive Cancer Network's Prostate Treatment Guidelines Committee.
"The PSA has overshot its goal," he said. "It often finds prostate cancer when it is so low-risk that it doesn't need to be treated," he said. "But you also can't deny that the death rate for prostate cancer has fallen 40 percent since the PSA."
Mohler said Roswell Park doctors are aware that the PSA test might overdiagnose prostate cancer and put men at risk of complications from unnecessary treatments. But a critic contends the cancer center does a poor job of alerting men to the limitations of the PSA test on its Prostate Club for Men Web site.
"The Roswell Park Cancer Institute in Buffalo has a reputation as one of the finest cancer care facilities in the country. But their promotion of prostate cancer screening doesn't match that reputation," Gary Schwitzer, a health journalism professor at the University of Minnesota, recently wrote in his blog and an opinion piece in The Buffalo News.
The Web site fails to offer information about the uncertainty, harms of screening or the importance of careful, shared decision-making in screening and treatment, according to Schwitzer.
He cited an editorial by the Cancer Society's Brawley, who wrote about hearing a commercial that claimed prostate cancer is 100 percent curable when caught early and encouraged all men to get screened.
"A commercial like this plays to our fears and prejudices," Brawley wrote. Schwitzer contended much of the Prostate Club Web site language does the same.
Proper use urged
Mohler strongly defended the marketing efforts on the Internet, radio, billboards and other media, describing it as primarily an awareness campaign to help men gain control of their health.
"Talking to your doctor about prostate cancer screening is not the same as being treated," he said.
He said Prostate Club members are encouraged to learn about prostate cancer and to talk about the appropriateness of testing with their physicians. The cancer center started the club in response to patients who complained about being rushed into treatment, he said.
"Half the men undergoing treatment in the U.S. don't need it. But we can't say with 100 percent certainty who doesn't need treatment," Mohler said. "I'm not a proponent of universal screening. I'm for the proper use of the PSA. We have to use the tool available to us intelligently and not overtreat."
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