This must be the week for cancer screening stories and reports, some of which are clearly crafted to alarm people who read them or watch them. A segment on this morning’s NBC Today Show is a case in point, along with the original story on the Reader's Digest website which served as the basis for the TV segment. A report earlier this week about the “over diagnosis” of prostate cancer as a result of screening was another.
What was missing from these various presentations and reports is a sense of balance about who has said what, which organization has made what recommendation, and an honest commentary that is meant to inform rather than frighten.
When I read the original article and watched the video of this morning’s segment, I began to wonder how many people who viewed that information came away truly informed about the issues, the science and the facts (Matt Lauer’s concerns notwithstanding).
Let me make something perfectly clear: comments that screening for cancer isn’t the answer to reducing deaths from every cancer are not new. Also untrue is the implication that those of us who advocate screening for certain cancers aren’t aware of the risks of screening.
We have always known that there are a variety of ways that cancers behave in our bodies. We have known for decades that there are cancers found on autopsy studies or incidentally through other means that never caused anyone any problem. The classic examples I learned about in medical school over 30 years ago included thyroid cancer, breast cancer and prostate cancer.
Now, with our improved abilities to search our bodies with advanced imaging techniques such as ultrasound, CT scans, and MRI scans, we are indeed finding more and more cancers that fit the definition of an “indolent” cancer.
To say that we are not aware of the variability of the natural history of cancer, or the fact that we will pick up cancers that would never cause a problem, or that there may be harms from the biopsies and treatment for cancer is a misrepresentation of what we know and what we do when it comes to recommendations for cancer screening. We think about those issues every day, at least here at the American Cancer Society. We talk about them, we argue about them, we write about them.
Yes, we do believe that the scientific evidence shows that mammograms save lives. We do believe that colorectal cancer screening saves lives (and could save a lot more if we had more people screened). We do believe the Pap smear has been incredibly successful in reducing deaths from cervical cancer in the United States and other developed countries. Just take a look at what happens in the rest of the world when it comes to cervical cancer, and the fact that women all over this planet are dying from this disease because they don’t have access to any form of screening or treatment for what is now a largely preventable disease.
The reason we accept the risks of over diagnosis and treatment is that we believe the evidence shows that these screening procedures—when applied to large numbers of men and women—do save lives. But, we are not blind to the questions that must be raised and must be answered before a population-based recommendation is made.
Then we find ourselves presented with anecdotes such as those shown on television where a woman says she has decided against mammography, or someone decides they don’t want to undergo colonoscopy. Those are individual decisions that all of us make at one time or another in our lives. Even I have declined to get certain recommended tests from time to time based on my knowledge and considerations of benefits and risks.
Those are personal decisions. But when the American Cancer Society makes recommendations for the prevention and early detection of cancer, we have to consider what is the best course of action that applies to hundreds of millions of people.
We don’t know who is going to get cancer and who is not. We don’t know which cancers are potentially lethal and which ones are not. We don’t know which cancers are going to be impacted in a good way by being found early and which ones are not.
All of those questions are legitimate to ask. But all of those questions also require further research—which is ongoing and funded by a number of organizations—to help us get the answers.
Until we have those answers, we also realize that our approach to screening and treatment sometimes is a lot more “rough-cut” than we would like. But we are also of the opinion that we need to accept that significant limitation, understanding that lives hang in the balance.
We also recognize very clearly that when we don’t have the evidence that screening works, we say so. Such is the case with prostate cancer screening, where we clearly advocate that men have a discussion with their doctors or other health care professionals to discuss the pros and cons of prostate cancer screening, as outlined in my blog earlier this week.
If I seem a bit angry and perturbed about this debate, it’s not because I am a true believer that every cancer could be caught early (they can’t; screening isn’t perfect) or that every cancer caught early represents a cure (that’s not the case). But I have been around long enough—unlike some folks—to remember what life was like in the 1960’s and 1970’s before we had any of this evidence about screening.
I remember what it was like to treat women with “early” breast cancer in the days before effective mammograms were available, when a lump was palpated by the woman or her doctor and we told her it was “early” cancer. Many of those women went on to die from their disease. The cancer wasn’t early, and we didn’t have particularly effective treatments.
I remember women walking into the emergency department with towels wrapped around their breasts, bleeding from a mass or having discharge from the nipple. There was no screening, and living five years for many of these women was considered a miracle.
I remember the data from a large national breast cancer treatment research group published in 1969. Their report discussed the size of the average breast cancer, and the number of lymph nodes involved at the time of diagnosis for a large number of women. The bottom line: the overwhelming majority of breast cancers approached an inch or larger in size, and the majority of women had lymph nodes involved with cancer. The verdict was in before the treatment could be applied.
We used to take women to the operating room telling them they may wake up without their breasts, and routinely did extensive surgery under their arm to take out their lymph nodes. We thought that doing this type of surgery would save lives. And then we learned over the next number of years how wrong we were.
I remember caring for people who developed rectal bleeding and were found to have colon cancer. We didn’t have screening tests back then, and it wasn’t until some time later that we learned—through a clinical trial—that checking the stool for blood could reduce deaths from the disease. Now we have effective tests to reduce deaths from colon cancer, yet we still have too many people dying from the disease.
To suggest that we have hurt more than we have helped through screening for those cancers where the evidence shows otherwise is in my personal opinion ludicrous. Problems with early detection that need to be recognized and discussed? Yes. Worthless or overall dangerous? No, not when the benefits and risks are carefully considered.
I have no desire to go back to the good old days before we screened for various cancers.
I too look at data and I see the decline in deaths from colorectal cancer, breast cancer and cervical cancer. And, as I point out in my lectures every time I discuss this issue, I see the decline in stomach cancer which I point out cannot be attributed to screening (it may be attributed to other lifestyle changes, or perversely to the overuse of antibiotics).
But I also show a slide which shows the dramatic decline in cancer death rates beginning in the early 1990’s which has occurred in large part because of a reduction of smoking and more effective screening and treatment for some of the common forms of cancer.
I also use slides that show the disparities in deaths among whites and African Americans in this country for breast cancer and colorectal cancer. Those disparities did not exist before screening for those diseases became widely adopted. Now, we try to pacify ourselves that there must be a biologic difference in disease related to race. I will leave it to the experts to argue that point, but from where I sit it sure looks suspiciously like an access to care issue, with difficulty for too many in the African American community to get appropriate screening and treatment.
I would suggest that cancer screening—as imperfect as it may be—is not the place to start cutting back on your health care.
Yes, we need to make certain that we understand the benefits and risks of screening before making recommendations to everyone as to what they should do. We need to make certain that men understand what we know and what we don’t know about prostate cancer screening. We need to complete the clinical trials to find out whether or not lung cancer screening and prostate cancer screening really saves lives. We need to fund research to help us develop better approaches to screening which will hopefully help us pinpoint which cancers we need to worry about, and which ones we can leave alone.
But until that time of perfection comes, please do not provide us with scare stories or horror stories that strike fear into our hearts. Inform us, educate us, guide us. But do not scare us. That is a terrible disservice, in my opinion.
Please, please, please do not take us back to the days of yore when the word cancer was spoken in hushed tones and no one dared discuss it with their loved ones because the outcome was almost always horrific.
I have been there, done that, and don’t want to do it again.