November 17th, 2010
12:08 PM ET

Doctor's voice: The engine of cancer screening rolls on

Recently, I heard the expression “cancer screening engine.”  It was used in the context of cancer screening being very powerfully focused, with a momentum that—for better or for worse—is hard to alter. The public fracas over the U.S. Preventive Service Task Force's guidelines for mammograms a year ago this month is an example of the depth of resistance.

The cancer-screening engine has permeated doctors’ thinking as well, as shown in a recent study in the Journal of the American Medical Association. Thousands of patients with advanced (incurable) cancer, were getting routine screening tests (PSAs, mammograms, colonoscopies) for other cancers.

This, of course, is incorrect medicine. Any patient with a life expectancy of less than five years (whether from cancer, heart disease, or emphysema) should not be getting screening tests. Screening tests will not prolong their life or improve their quality of life. On the contrary, treatments for new diseases will likely impair the quality of their remaining time.

Most doctors know this, or should know this. Yet, the cancer-screening engine rolls on, oblivious to the fact that screening is a nuanced proposition that needs to be considered differently for different groups of patients.

As much as I hate to think about it, there are likely profit motives mixed in. There are all sorts of commercial entities that stand to gain with an aggressive indiscriminate screening message. Mammography is a big business. Imagine a high-tech product (iPhone or Android for example) that 25 percent of the population needs to purchase every single year. Somebody, somewhere, is raking in boatloads of money.

This is not to deride screening, or the important work that advocacy groups have done. As a primary care doctor, screening is one of the things I address with every patient at every visit. But the accuracy and specificity of these cancer screening tools are nowhere near as absolute as we would like—or as the public believes.

Unfortunately, conveying nuance and uncertainty is not a strong suit of the media, the public discourse, or doctors, for that matter. Everyone wants clear, definitive answers from a situation that will never be able to offer one.

I am an admirer of the American Cancer Society and the breast cancer awareness groups, but I get concerned when advocacy eclipses reality. As a result of years of advocacy work, most of the public currently believes that one of every eight women gathered in a room will get breast cancer. They are also under the impression that mammograms are perfect binary tests, sort of like light switches—they flick on to indicate cancer or flick off to indicate not.

Neither of these statements is true; the reality is far murkier. But complex, imperfect scientific facts rarely translate into sexy poster slogans.

Cancer screening is critically important in medicine. But there is a danger that the screening engine in our society is a one-track train, plowing forward, staying “on-message,” not to be bogged down with conflicting data, nuanced reasoning, or messy statistical analyses.

Danielle Ofri is associate professor of medicine at New York University School of Medicine and editor-in-chief of the Bellevue Literary Review. Her most recent book, “Medicine in Translation: Journeys with My Patients,” is about the care of immigrants and Americans in the U.S. health care system.

soundoff (31 Responses)
  1. Tom

    They want cancer to keep going. You expose yourself to radiation that causes cancer to test you for cancer. I heard on that radio that they actually now want women to get mammograms every 2 years!!!!!!!!!!!!!!!!!!!! Are they out of their freaking minds? No they are not. They know EXACTLY what they are doing. Everywhere you go there is 'money going towards the susan g komen foundation. Its sickening that they are capitzaling off people dying of a terrible illness. Cancer will not go away.

    November 17, 2010 at 14:45 | Report abuse | Reply
    • Pam

      Be quiet Tom. As a cancer survivor (twice) I will have all the test necessary done!!!! I am being proactive with my healthcare. I am not sitting in the cornor with my back to the world like you.

      November 17, 2010 at 16:40 | Report abuse |
  2. Wandering Bear

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    November 17, 2010 at 15:14 | Report abuse | Reply
  3. Jen

    blanket statements either way can be extremely detrimental - this doctor that wrote this is very irresponsible in this article in that the very first thing she should have said was: EVERYONE'S SITUATION IS DIFFERENT AND YOU MUST SPEAK IN LENGTH WITH YOUR FAMILY AND YOUR DOCTOR ABOUT YOUR CHANCES OF CANCER....

    many people are carrying around genetic cancer and do not even realize it - my husband has Lynch Syndrome which is a gene mutation that causes primarily colon cancer in people under the age of 50 - his father had/died from cancer, his older brother had/died from colon cancer - my husband AT THE ADVICE OF A BOARD CERTIFIED GI doctor, only did colonoscopies every 3-5 years - well turns out my husband got diagnosed with TWO CANCER TUMORS (1 of them stage 3b, the other stage 1c) - 6 months from stage 4 (this cancer progresses extremely fast) after going 3.5 yrs between coloscopies - now how is it that my husband who FOLLOWED advice JUST LIKE THE ONE THIS DOCTOR recommends - almost die? because he was supposed to have colonoscopies EVERY SINGLE YEAR and endoscopies EVERY SINGLE YEAR for barret's esophogus.... i would personally punch this doctor in the face for this article, because it is EXACTLY this type of "knowledge" most doctors have that almost killed my husband!

    November 17, 2010 at 15:34 | Report abuse | Reply
  4. ru4real21

    Well, my oncologist certainly never told me that advanced cancer means I won't be here in five years – oops, make that three years now! What a sweeping generalization, and how detrimental to cancer patients who don't intend to give in to this disease to have further screenings discouraged. In the future, the good doctor should think about the potential impact of her statements on patients. If doctors don't stand behind health care rights for those of us with pre-existing conditions, who will?

    November 17, 2010 at 17:39 | Report abuse | Reply
  5. Jacob

    I'm pretty sure 1 in 8 is the accurate lifetime risk for developing breast cancer. A quick google search (for: lifetime prevalence breast cancer) brings up reliable statistics (SEER study: http://seer.cancer.gov/statfacts/html/breast.html) that show 12.15% lifetime risk.

    The reason screening is adopted is that large randomized trials (between screening or no screening) show significant improvements in survival for the screening group. 60% of breast cancer is detected at a localized stage because of screening. 98% of those patients are alive 5 years later. If you take out screening then a much higher percentage of women get caught at a later stage, after the disease is spread, and that means that a lot more of them die. Recently similar studies have shown that screening lung cancer with chest CTs improves survival compared to not screening.

    Now, that being said, it is a hugely expensive endeavor. There is definite benefit that really can't be argued with, but it costs a lot (and also causes invasive biopsies that can sometimes hurt people who don't have cancer). So the question really becomes whether we get the most out of our health care dollars by ramping up screening, or by putting our money elsewhere. And that, as the author says, is much murkier.

    November 17, 2010 at 18:14 | Report abuse | Reply
    • Danielle Ofri

      Just to clarify: Yes, there is indeed a 1 in 8 lifetime risk for breast cancer. However, saying that 1 of every 8 women sitting in a room (or on a poster) will get breast cancer is not the same thing. These are very different statistics and my concern is that the publicity for screening has allowed a misperception to gain traction. Hope that helps.

      November 18, 2010 at 12:54 | Report abuse |
  6. Bob

    There most certainly is a profit motive here but there also is a problem with patients and their families understanding that excessive tests take resources away from others. Sarah Palin was protecting the status quo when she was complaining about death panels. Unfortunately the Glenn Becks of the world don't really care about anyone but themselves and they refuse to tell the truth. Unfortunately the uneducated public buys this garbage. The uneducated American public needs to get educated with regard to health care so that they can understand that the public option with testing restrictions is in everyone's best interest.

    November 17, 2010 at 18:31 | Report abuse | Reply
  7. John

    A recommendation against cancer screening in an individual with a life expectancy of less than five years is problematic. Assume a female with metastatic breast cancer is told by her oncologist to avoid further cancer screening as her life expectancy is less than five years. She avoids going to her routine cancer screening by her dermatologist. One year later she is discovered to have a melanoma on her back, and dies 3 months later because of this aggressive cancer. The melanoma would have been detected and removed had she kept her yearly appointment. The oncologist would likely be sued for millions of dollars for giving her that information in our current health care system. Our medical malpractice standards prohibit giving such advice. Another thought is the potential possibility of a breast cancer cure in two years.

    November 17, 2010 at 19:46 | Report abuse | Reply
  8. Alinnc

    The responses so far are pretty much on track. The main thing is that everyone has a different risk of different cancers. You need to understand what your risks (odds) are and you need a physician that will work with you as an individual to determine what screenings and frequency of screenings are indicated. As far as death panels, extensive evaluations on various screenings and treatments have been done and updated for years. Although not perfect, they try to assess benefits (cure, extended life span even if there is no cure) versus problems such as severe side effects, negligible improvement in outcome, false positives, and even cost. This may not be beneficial to an individual patient – they may have been the 1 out of 100,000 that got an early detection from a $1,200 screening test, but despite what some people want to believe, there is a limited amount of money that can be spent on health care. The $120,000,000 spent doing that screening that saved one life may have been more effectively used to address other health care issues that may save hundreds of lives.

    November 17, 2010 at 20:01 | Report abuse | Reply
  9. charles s

    If the cancer has metastasize then more screening will certainly find more cancer but it will not change the prognosis. That is what Dr. Danielle Ofri is saying. A patient can have more surgery and more chemo therapy and it might prolong their lives but the outcome is already done. Chemo therapy is about 3% effective in eliminating cancer. Read the following article about chemo therapy for cancer:
    The information in this article is based upon an article published in Journal of Clinical Oncology Volume 16, Issue 8, December 2004, pages 549-560.

    November 17, 2010 at 21:18 | Report abuse | Reply
    • lalaland

      Everyone responds differently to chemo and what type of chemo you have. What it does to everyone -kills off good cells as well as the bad. I was supposed to have 6 rounds, thought I was going to die, advocated for a f/u MRI and my tumors had decreased enough in size to get the surgery sooner so only had 4 cycles. So NO I did not want chemo, and YES, I stopped it early, but it WAS WORKING, even if it was killing me at the same time......Charles unless you personally have cancer you won't understand. Sincerely, everyone has their own journey if your diagnosed with cancer, I think advocating for yourself is needed by all and be a part of your treatment plan. I have refused many treatments or procedures others don't-again it's a journey a person with cancer can only understand...

      November 18, 2010 at 10:20 | Report abuse |
  10. lalaland

    Being a 31 year old breast cancer survivor since 9/28/10...I have a lot to say, but will make it brief. Screenings are necessary for women over 40! IT TOOK ALMOST A YEAR FOR A DOCTOR TO ORDER A MAMMOGRAM FOR ME DUE TO MY AGE & NO FAMILY HISTORY OF BREAST CANCER, TOO LONG I MUST SAY; IT WOULD HAVE BEEN AN EARLIER STAGE AND MAYBE i WOULD HAVE BREASTS INSTEAD OF LOOKING AT MY CAVED IN CHEST I HAVE NOW. I opted for a double mastectomy, in part, that it would decrease further scans and tests, as well as cancer in the future and was required for one of my breasts anyway. HOWEVER; I have been approached by 2 young women (my age) that have lumps in their breasts and have either had a mammo, or nothing at all! MAMMOGRAMS ARE NOT A USEFUL TOOL IN DIAGNOSING YOUNG WOMEN WITH BREAST CANCER! Our breast TISSUE IS TOO DENSE, we need to have MRI'S and unfortunately many insurances won't pay even if you feel a lump, or the dr ignores it, let me see you in 6 months, yadayadayada! ADVOCATE for yourself, do what you think is right! Don't let docs disregard any lumps....Christina Applegate has an organization for young women, which specifIcally funds MRI's

    November 18, 2010 at 10:11 | Report abuse | Reply
  11. tiredOfIt

    This is an example of the many bad things that happen when you mix capitalism with medicine and don't put enough restrictions on the capitalism.

    November 18, 2010 at 12:44 | Report abuse | Reply
  12. gpawelski

    The efficacy of screening for any medical condition depends not only upon test accuracy, but upon the efficacy of proceeding with definitive diagnosis and therapy versus the efficacy of doing nothing at all. There is no doubt that screening may identify cancer at an earlier stage than in the absence of screening.

    Biologically, it appears that many cancers diagnosed at an earlier stage with screening are so aggressive that even at the time of earliest possible detection, there are already micrometastases, meaning that earlier extirpation of the primary tumor does not influence outcomes in a meaningful way.

    More commonly, tumors are so indolent that metastases would not have occurred, even had diagnosis been delayed by one, two, or several years (i.e. until the lesion became palpable and was diagnosed in the former, pre-screening manner).

    So the only patients helped by screening are those who are accurately detected by the screening exam and which have a "goldilocks" biology – not too aggressive, not too indolent. Balanced against this is the harm caused by screening, with respect to the false positives and the underlying morbidity of the screening procedure (e.g. radiation exposure).

    November 18, 2010 at 13:56 | Report abuse | Reply
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