To screen or not to screen?

Controversies in medicine are nothing new. On a seemingly regular basis, a new finding contradicts an old finding, which may in fact have contradicted an even older finding. Patients and practitioners alike are left to sort out the science.

When the controversy surrounds a frightening and too-often-fatal disease like cancer, the stakes and stress are even higher. That’s why Enloe Medical Center, in partnership with UC San Francisco, has planned a conference on the evening of Nov. 15 to help the public sort out controversies in cancer screening.

The event’s title—Cancer Screening: How Much is Too Much? How Much is Enough?—encapsulates the overarching concern.

“What’s really upsetting to patients is that every few years the recommendations for cancer screenings change, and it’s always [that patients get screened] less and less [frequently],” said Dr. Michael Baird, executive director of the Enloe Regional Cancer Center. “People are getting paranoid: Is this real, or is it just being done to save money?

“In today’s climate of health-care costs going up, patients are a little suspicious when federal groups or other large consortiums start saying, ‘Well, you don’t need a mammogram every year.’ Is that because I don’t need a mammogram every year, or just because they don’t want to pay for a mammogram every year?”

The short answer, according to Baird, is a little of both. He’ll elaborate at the conference, but he didn’t hold back anything important in a recent phone interview with the CN&R.

“In general terms, most of those recommendations are appropriate when you are talking about the population as a whole,” Baird explained. “Let’s say one in 400 of a screening test is going to yield a positive result; that means you are wasting the money on 399 people for the one person you pick up. So if you are an insurer, you’re saying that’s a waste of money if it’s a very expensive test—but if you’re the one patient, it’s worth everything in the world to you.

“There’s another side to the issue: Sometimes it’s about the risk to the patient if you do find something. There’s no test that’s perfect—most tests just show an abnormality that may be cancer—and then it comes down to whether you’re finding cancer that’s really going to make a difference in their lives.”

Baird used prostate cancer as an example.

Doctors commonly recommend a blood test that checks the level of prostate-specific antigen (or PSA). The Centers for Disease Control and Prevention explain that “as a rule, the higher the PSA level in the blood, the more likely a prostate problem is present. But many factors … can affect PSA levels.”

The next step is a biopsy, in which a doctor extracts a small amount of prostate tissue for examination. That process, Baird said, is expensive, invasive and painful. “So if you’re doing biopsies on a thousand men for every one or two [prostate cancer cases] you find, you’re inflicting a lot of pain for a small amount of yield.”

Then comes the determination of how much the cancer will impact the patient’s quality of life. Some cancer types are more severe than others. Going back to prostate cancer, Baird said that “many of the cancers we’ve been picking up on screenings may or may not ever cause someone problems in their whole lifetime. But by labeling it as cancer and treating them aggressively with surgery and radiation, now you’re putting people through side effects, impotence, maybe infection and complications from surgery that maybe they didn’t need to have because maybe that cancer would have never affected them in their life.

“All of these things go together in how consortiums decide to recommend something or not,” he continued. “You as a patient sitting out there … need to think through what your risks are.”

How does a person, in conjunction with a physician, determine cancer risks?

History has a lot to do with it. Certain cancers are more prevalent in people of certain ages and ethnicity. Genetics also may play a role, so a person with relatives who have had cancer could have a greater chance of developing that same condition.

Even then, different doctors may have different opinions—and may have opinions that differ from recommendations put forth by agencies or associations.

Again, look at prostate cancer. The U.S. Preventative Services Task Force came out in May with a finding that discourages PSA screening. “Urologists totally disagreed with them,” Baird said. “The AUA [American Urological Association] said this is wrong; patients should continue to have screenings for PSAs.

“Of course, people said, ‘Well, that’s just economic because you guys just want to make money from all the biopsies.’ They said, ‘No, we’ve found many, many cancers that otherwise would have been terminal.’ … You can see the argument either way.”

The trick is finding a knowledgeable doctor you trust.

“If [cancer screening] is something your doctor is interested in and they stay up on it, it’s wonderful,” Baird said. “You can’t guarantee everyone is doing that. Most people in office practice will look at the recommendations of the big national groups and it’s sometimes hard to get any discussion past that.

“If someone has issues with screening—if they want to get screened and the recommendation doesn’t call for it, and they’re not comfortable with that—that certainly is a reason for them to sit down with somebody like an oncologist to determine if they’re right or wrong.”