Do Cancer Centers Push Too Many Tests?

Let’s say a postcard arrives in the mail, a reminder to make an appointment for a mammogram. Or a primary care doctor orders a PSA test to check a man for prostate cancer, or tells him that because of his years of smoking, he should be screened for lung cancer.

These patients trying to be informed customers can search for a cancer center online to learn more about screening, when it is recommended and for whom.

This may not be the best move. The Medical Society and the independent US Preventive Services Task Force publish guidelines about who should be screened for lung, prostate and breast cancer and how often, among many other prevention recommendations. But cancer centers’ websites often deviate from those recommendations, according to three studies recently published in JAMA Internal Medicine.

The researchers found that some sites discussed the benefits of screening but said little about the harms and risks. Some offered recommendations about the age to start screening, but highlighted when to stop – an important piece of information for older adults.

Dr. Behfar Ehdei, a urologist at Memorial Sloan Kettering Cancer Center in New York and study author, said, “If we accept that these websites are important sources of information based on screening according to guidelines, we have little room for improvement.” There is scope.” On prostate cancer screening recommendations.

Screening refers to testing for patients with no symptoms or evidence of disease, including prostate-specific antigen testing, mammograms, colonoscopy, and CT scans.

Researchers analyzed more than 600 cancer center websites that provided recommendations for prostate screening, and found that more than one-quarter recommended that all men be screened. More than three-quarters did not specify an age to stop routine testing.

Yet guidelines from both the Preventive Services Task Force and the American Urological Association state that men over 70 should not be routinely screened because, according to the task force’s guidelines, “the potential benefit does not exceed the expected harm.” are.”

For men ages 55 to 69, both groups urge individual decision-making after a discussion about the benefits and harms with a physician. However, no group recommends routine screening for young men at average risk.

In addition, the study reported that 62 percent of cancer center websites do not include information about the potential pitfalls of screening. Because prostate cancer grows slowly, it often does not cause any problems. But detection and treatment can lead to complications from surgery or radiation, including lower quality of life from incontinence and sexual dysfunction.

Similar problems were found on websites discussing other cancer tests in the survey. In a study of more than 600 breast cancer centers, more than 80 percent of those recommended early age and interval for screening mammograms were contrary to the guidelines. The study did not address whether the websites included information about when to stop.

The Preventive Services Task Force’s 2016 guidelines, which are currently being updated, recommend screening mammograms every other year for women ages 50 to 74; It found insufficient evidence of benefits and harms for people 75 years of age and older. The American Cancer Society recommends annual or biennial screening for women over age 55 at average risk, as long as they have a life expectancy of 10 years.

However, lung cancer screening is recommended only for people who are at high risk because of smoking history and older age. Here too, an analysis of 162 cancer center websites showed that almost half did not address the potential harm.

An internist at The Ohio State University College of Medicine and senior author of the study, Dr. “We think it’s important to present a balanced account,” said Daniel Jonas. “It’s fair to say they can do a better job.”

Concerns about over-testing and over-treatment of certain cancers in older adults have persisted for years. An internist and health care researcher at Beth Israel Deaconess Medical Center in Boston, Dr. “The pitfalls of screening happen quickly,” said Mara Schoenberg. But the benefits of screening can be reaped years later; Older patients with other health problems may not live long enough to experience them.

For example, with mammography, disadvantages include false positives, leading to repeated mammograms or biopsies, the psychological consequences of which can persist for months, Dr. Schönberg’s research showed.

And while most breast cancers diagnosed in women over 70 are very low-risk and may never progress, “almost all are treated with surgery,” Dr. Schoenberg said, and sometimes with radiation and endocrine drugs, all of which can have negative side effects. ,

To benefit, the data showed that 1,000 women aged 50 to 74 would undergo mammography for about 11 years to prevent one death from breast cancer.

Why would some cancer center websites exclude possibilities such as false positives, repeat tests, radiation exposure or after-surgery effects? Why don’t they include information about how many lives are actually saved at a particular age?

“In the American health care system, the more procedures you do, the more you get paid,” said Dr. Alexander Smith, a palliative medicine specialist and geriatric researcher at the University of California, San Francisco. Radiology, which is essential for both lung and breast screening, “is one of the biggest money makers for health systems,” he said.

Dr. Jonas said that some websites are developed by marketers with little input from health professionals. Talking about the risks may discourage patients from clicking the “make an appointment” button.

On the other hand, it may be harder to refuse screening to older patients, even if research shows little benefit.

Dr. Schönberg developed and tested decision aids – pamphlets that help women over 75 and their doctors reach evidence-based conclusions about mammograms.

To some extent, they work. Older women who receive pamphlets are more knowledgeable and more apt to discuss the benefits and risks with their doctors; They are less inclined to continue screening. But at 18 months, nearly half of the women who received decision aid had mammograms anyway, as did 60 percent.

Dr. Schönberg explained this as habit or “the need for reassurance”. Patients may also underestimate their level of risk; They reported that the average 75-year-old woman has a 2 percent chance of being diagnosed with breast cancer over five years.

In addition, screening options involve a problem some older patients (and doctors) prefer to avoid: life expectancy. The American Cancer Society and some medical groups use a life expectancy of 10 years instead of the age cutoff, when older patients can stop screening.

“Prognosis is one of the key factors in decision making,” Dr. Smith said. “Will patients live long enough to experience benefits?” It can be an uncomfortable conversation involving age, health and mortality.

How should older adults inform themselves about cancer screening? In addition to discussing the pros and cons with their doctors — such a visit is required before Medicare covers lung cancer screening — patients can visit the U.S. Preventive Services Task Force website for the latest assessments. .

They can also use ePrognosis, an online guide developed a decade ago by Dr. Schonberg, Dr. Smith, and colleagues at UCSF. Most visitors are health care professionals, but patients can also use the site’s calculators to determine if they are likely to benefit from breast and colon cancer screening. They can use questionnaires that help determine their expected life expectancy, as well as a number of decision aids.

Of course, patients can also consult cancer center websites – but keeping an eye on what may be lacking.