The Problem with Breast and Prostate Cancer Screening

New reports today are that the American Cancer Society is rethinking its position on advocating for aggressive screening of breast and prostate cancers. The lack of evidence of the benefits of screening has been around for a while (just ask UNC’s Dr. Nortin Hadler). But Hadler’s campaign is drawing other researchers and finally bearing fruit:

Both [the PSA test and mammograms] have a problem that runs counter to everything people have been told about cancer: They are finding cancers that do not need to be found because they would never spread and kill or even be noticed if left alone. That has led to a huge increase in cancer diagnoses because, without screening, those innocuous cancers would go undetected.

At the same time, both screening tests are not making much of a dent in the number of cancers that are deadly. That may be because many lethal breast cancers grow so fast they spring up between mammograms. And the deadly prostate ones have already spread at the time of cancer screening. The dilemma for breast and prostate screening is that it is not usually clear which tumors need aggressive treatment and which can be left alone.

This goes right to the heart of what is wrong with our health care system. Costs are skyrocketing, in part because of all these screening tests. Add in aggressive treatment for conditions that don’t need treatment – like, apparently, many “innocuous cancers,” and you are really wasting money. That’s not the worst of the problem however. This overtreatment means that our medical system often delivers what North Hadler calls “type II medical malpractice” or excellent care delivered very well that is completely unnecessary and ineffective.

Even excellent care can have serious side effects. Think about the estimated 20% of men who undergo treatment for prostate cancer who end up either incontinent, impotent, or have other serious side effects. And this is for excellent treatment delivered well. The catch? Many didn’t need the treatment in the first place.

This is going to be one of the most wrenching changes in our crazy health care system. We believe we should get every test, every treatment no matter what. But this really isn’t solely or even primarily a matter of cost. Overtesting and overtreatment means delivery of care that is ineffective and harmful. The current reform bills move us towards addressing these issues with money for research on the comparative effectiveness of treatments, drugs, and other procedures. But changing people’s attitudes about how they and their families get health care will be the real challenge.

12 Comments

  1. [...] View original post here: The Progressive Pulse – The Problem with Breast and Prostate … [...]

  2. Rod

    October 21, 2009 at 12:13 pm

    Your claim is a little naive and off base. Often the most treatable cancers are the ones that are caught early and for–prostate cancer especially–non aggressive cancers caught early can make a huge impact without requiring major treatment like RP, RT, or HT. in fact research supports that medical management with non-harmful agents like pomegranate can mean the difference between a cancer turning from a pussycat into a tiger. . .

  3. [...] Go here to see the original: The Progressive Pulse – The Problem with Breast and Prostate … [...]

  4. Aftercancer

    October 21, 2009 at 3:37 pm

    I have to question the validity of comparing breast cancer to prostate cancer in terms of whether it needs to be treated. Prostate cancer, in most cases, is a very slow growing cancer. Breast cancer has variable growth times so it is much harder to determine which patient has the cancer “that would never spread, kill, etc”. A a breast cancer survivor diagnosed at age 38 you’ll never convince me that screening for breast cancer is not beneficial, even if the answer is watchful waiting.

  5. Adam Searing

    October 21, 2009 at 7:28 pm

    I think we have to go by the increasing body of evidence – like the American Cancer Society is now doing – and the increasing body of evidence supports less screening in many cases. I’m all for screening if we know it is effective. But I don’t think ACS, who has erred on the side of screening on this question for many years, is rethinking its position lightly.

  6. Amy Swygert

    October 21, 2009 at 7:52 pm

    I work for the American Cancer Society and want to be sure that your readers know that Society continues to believe in the importance of cancer screening (particularly breast, cervical and colon cancer screening) and stands behind its current screening guidelines which can be found here http://bit.ly/LrXWv. Earlier today, the Society issued a statement from our Chief Medical Officer Otis Brawley about the New York Times story http://bit.ly/32CMqH and the Society’s Deputy Chief Medical Officer, Dr. Len Lichtenfeld, blogged about the story behind the story here http://bit.ly/25O8aK.

  7. [...] The Problem with Breast and Prostate Cancer Screening - The Progressive Pulse [...]

  8. IBXer

    October 22, 2009 at 12:21 pm

    I am sure we will all be a lot heathier when we can only get the care the government deems cost effective…

  9. Adam Searing

    October 22, 2009 at 3:26 pm

    Thanks Amy for commenting and clarifying that ACS continues to support their current guidelines on screening as they continue to review the literature. I think that is the only position that makes sense!

    However, I would disagree with some of ACS’s Dr. Len Lichtenfeld’s thoughts you cite about public reporting of this type of review. I think that full and open debate is important around issues like the efficacy of screening – especially given the high stakes involved. While they might not be perfect, stories like the NYT’s move that debate forward.

    I think it is a disservice to the many thoughtful people we have spoken with all over North Carolina about the complex ins and outs of health reform this summer to think that they – as Dr. Lichtenfeld asserts – “will miss the nuances of the experts’ arguments” on debates like this. On the contrary, our experience has been at the Health Access Coalition that people are becoming increasing well-versed in some pretty complicated issues around health care and are able to articulate those views and add to the debate.

    We all want what is best for people facing serious disease and that’s why both ACS and the NC Justice Center and many, many others support health care reform. As we win that debate however, we are starting to have the luxury of approaching the many other questions on how to improve the effectiveness and quality of care, which many turn out to be even tougher!

  10. jeffrey dach md

    October 23, 2009 at 7:23 am

    Although PSA screening eradicated advanced prostate cancer from the population, there was a downside.

    According to Welch’s report in August JNCI, one million men were overdiagnosed and overtreated for prostate cancer over the last twenty years.

    Why was PSA Screening for Prostate Cancer, a 20 year failed Medical Experiment ? Get the whole story here…

    http://jeffreydach.com/2009/10/01/psa-testing-the-failed-medical-experiment-by-jeffrey-dach-md.aspx

  11. [...] the American Cancer Society, although it hasn’t changed its current recommendations, is reported to be reevaluating the evidence on certain types of screening as [...]

  12. [...] written before here about the reasons why the PSA test for prostate cancer isn’t worth doing as a general [...]