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To Screen or Not to Screen, That is the Question


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“today’s cancer screenings can unearth tumors that scientists say never would have threatened the person’s life. The problem is that there aren’t surefire ways to tell in advance which tumors won’t be dangerous.” Adds Dr. Len Lichtenfeld, Deputy Chief Medical Officer at the American Cancer Society, “We’re really at a tipping point right now where we have a trade-off between the benefits of finding cancer early and the harms that are caused. We treat more patients than we know will benefit, we just don’t know who they are.”

Well that’s just great. What is a consumer to do? As usual, the answer is, “good question.”

This whole area is particularly contentious in light of the effort underway to reduce the cost of healthcare overall. Whenever the debate about cancer screening arises, particularly when it comes down on the side of “less is more,” both providers and consumers get pretty freaked out. Remember last year when the U.S. Preventive Services Task Force recommended ending mammograms for women between 40 and 50 because those mammograms were deemed to be largely ineffective in screening for cancer and had significant negative side effects? Who would have thought that millions of women would rise up and demand the right to stick their breasts into what feels like a waffle iron if solid scientific evidence suggests that it may not be helpful?

Any attempt to limit cancer screening is generally met with the assumption that there is a vast conspiracy to withhold care to reduce costs. Even if that is true, and it probably is when you get right down to it, the intent isn’t always sinister. Tightening up the screening rules may also have some significant advantages to consumers. The big challenge lies in the lack of consensus, even among medical experts, about when screening is necessary and when the negative side effects (such as false positives and the resulting unnecessary additional diagnostic and treatment interventions) outweigh the benefits. In the debate over the appropriateness of mammograms for breasts that have yet to feel the effects of gravity, the American Cancer Society and the American College of Radiology pit themselves against the American College of Physicians and the National Women’s Health Network. If you’re the patient, how do you know where to cast your vote?

This area of medicine, like so many others, sits squarely in the environs of art vs. science. What the powers that be end up telling you is, “ask your doctor.” And yet, what if your doctor just doesn’t know the right answer? If they are advocates of both the American Cancer Society and the National Women’s Health Network, which team jacket are they going to wear?

One area that seems to be an obvious place to eliminate screening tests is among those people who clearly do not need them at all. For instance, government guidelines suggest that men over 75 shouldn’t bother with PSA tests, themselves controversial even for younger men. However, about 1/3 of men over age 75 do get PSA tests, despite the fact that these men rarely die from prostate cancer. A 2004 study found that nearly 10 million women had received Pap smears (the screen for cervical cancer) despite having had total hysterectomies (including removal of the cervix) for noncancerous reasons. Ok, that’s just lame. And it’s what leads to the charge that … Next Page »

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