Sometimes it seems as if doctors cannot make up their minds. Caffeine is bad for you…no it’s not. Alcohol is good for you…no it’s not. More carbohydrates…. no we mean less. “Scientific Progress” can make your head rotate 360.
In recent weeks, three significant changes have occurred in medical screening. The recommendations for PSA, PAP and Mammograms were revised dramatically. Briefly, let us clarify these areas of health screening, as we understand them today.
Prostate Specific Antigen (PSA) is a blood test that is intended to detect or monitor prostate cancer. PSA is a protein made by prostate cancer, measured in the blood. For a man with active cancer, PSA is a reliable way to follow changes in the disease. However, the question is whether PSA can detect early cancer and save lives.
On October 11, The US Prevention Services Task Force (USPSTF) published a draft recommendation. The USPSTF no longer recommends routine screening using PSA. The USPSTF reviewed 31 studies and concluded that there was no reduction in death after ten years of PSA screening. The main problems are that a high PSA does not always mean prostate cancer and that PSA cannot distinguish aggressive prostate cancer, needing treatment, and slow growing prostate cancer, which does not.
It is unlikely that a man who is at average risk for prostate cancer will have his life saved by the blood test. He may however be harmed by treating insignificant “disease.” It is important to work with a doctor to identify special risk (family history, very large prostate gland, African-American race, prior negative or borderline prostate biopsy). For those not at increased risk, screening PSA has not been proven to save lives.
The Papanicolaou test (PAP) saves thousands of lives every year. By sampling small numbers of cells from the cervical lining during a pelvic exam, precancer or cancer can be detected. This screening test absolutely protects against death from cervical cancer.
The long-standing recommendation for yearly PAP smears has changed. PAP smears should not be performed at all for women younger that 21 years old, regardless of sexual history. PAP smears should also not be performed on women older than 65 who have had prior negative PAP smears. Most importantly, women 21 to 65 years, who have a cervix and have had sexual intercourse, need only have a PAP smear every three years. PAP smears are not recommended for women who have had a total hysterectomy.
Women should make risk decisions in consult with gynecologists. More frequent PAP smears may be warranted if there is increased risk such as prior abnormal PAP, HPV positivity, HIV, smoking, or DES use in patient or mother. As the HPV Vaccine is increasingly utilized it is likely that PAP smears will be found to have even less value.
Finally, mammograms took another hit last week. Mammograms detect the tiny flecks of calcium that can signal cancer. The authors of an article published in the Archives of Internal Medicine, estimate that routine mammograms performed yearly for ten years on 1000 women, would save just one life. Each year we spend five billion dollars to screen 39 million women. The study finds that while 138,000 breast cancers are found yearly by mammograms, and more than half of these patients are cured, only 10,000 of those women are cured because of the mammograms. 10,000 is not a small number, but is a relatively small portion of the 230,000 breast cancers diagnosed each year.
This study suggests that while most women with breast cancer are saved, most are not saved by a screening mammogram. While the study does not recommend stopping screening mammography, the authors are concerned that harm is being done to the other 38.99 million women who receive mammograms each year. The possibility of harm from radiation or excessive testing, in addition to the anxiety of the test, is a major concern.
Each woman must work with her doctor to design a cancer screening strategy. Personal breast cancer risk should be reviewed. It is important to discuss previous biopsies, obesity, smoking, estrogen use, radiation exposure and family history. If a woman is at average risk, it may be reasonable to get mammograms less frequently (perhaps similar to the every 3 year PAP?), but get professional breast exams yearly. There is little data to indicate breast self exams save lives. This data and study will be vigorously debated.
So how can we put all this together? First, look at your risks for cancer. Second, discuss choices with your doctor. Finally, understand your personal approach toward risk and testing. If you are the sort of person that wants to do everything and “take no chances” perhaps you will want to test more. If you are the type of person that is concerned about “unnecessary” testing, perhaps you will test less.
We should not forget that a key to avoiding cancer is not detection, but prevention. Improved diet, increased exercise, decreased weight, appropriate rest, moderate alcohol and smoking cessation reduce the chance of dying from cancer more than screening tests.
Medical testing is like all things in life, a balancing act. Health screening recommendations will continue to evolve and change. Thought, study, and discussion are key. Sticking your head in the sand is not an option. Moreover, just understanding your own comfort level and approach to life, may be the final guide.